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2021 Essential Health Benefits Base Formulary

Effective July 1, 2021

For the most current list of covered medications or if you have questions:

Call the number on your member ID card

Visit your plan’s website on your member ID card or log on to the OptumRx app to: • Find a participating retail pharmacy by ZIP code • Look up possible lower-cost medication alternatives • Compare medication pricing and options

EHB Base Understanding your formulary

What is a formulary? About this formulary A formulary is a list of prescribed medications or other When differences between this formulary and your pharmacy care products, services or supplies chosen for benefit plan exist, the benefit plan documents rule. their safety, cost, and effectiveness. Medications are This may not be a complete list of medications that are listed by categories or classes and are placed into cost covered by your plan. Please review your benefit plan for levels known as tiers. It includes both brand and generic full details. prescription medications.

® To create the list, OptumRx is guided by the Pharmacy and When does the formulary change? Therapeutics Committee. This group of doctors, nurses, and pharmacists reviews which medications will be covered, how • Medications, including generics, may be added at any time. well the work, and overall value. They also make sure • Medications may move to a lower tier at any time. there are safe and covered options. • Medications may move to a higher tier or be excluded from coverage on January 1 of each year. How do I use my formulary? If a medication changes tiers, you may have to pay a different You and your doctor can use the formulary to help you amount for that medication. choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and Why are some medications excluded if special rules apply. If your medication is not listed here, from coverage? please visit your plan’s website or call the number on your A medication may be excluded from coverage under your member ID card. pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication. What are tiers? Tiers are the different cost levels you pay for a medication. What if I don’t agree with a decision about an Each tier is assigned a cost, set by your employer or excluded medication? plan sponsor. You, your authorized representative, or your doctor can ask for a coverage request by calling the number on your member ID card.

Medication tips

What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but they often cost less. What if my doctor writes a brand-name prescription? Over-the-counter If your doctor gives you a prescription for a brand-name medication, ask if a medications (OTC) generic or lower-cost option could be right for you. Generic medications are Talk to your doctor about OTC usually your lowest-cost option. options. Even though OTC What if I am taking a specialty medication? medications may not be covered by your pharmacy benefit, Specialty medications are used to treat complex conditions and are generally they may cost less than a higher in cost. Please note, not all specialty medications are listed in the prescription medication. formulary. Our specialty pharmacy can provide most of your specialty medications along with helpful programs and services. Call 1-855-427-4682 and ask if you can have your prescriptions delivered right to your home or doctor’s office.

2 Reading your formulary

The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX). Generic medications are shown in lowercase (for example, ).

Tier information Using lower tier or preferred medications can help you lower your out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible.

Drug Tier Includes Helpful Tips

Tier 1 $ Generic Use Tier 1 drugs to lower your out-of-pocket costs.

Tier 2 $$ Preferred Preferred brand-name drugs will generally have lower copayments than non-preferred brand-name drugs.

Tier 3 $$$ Non-Preferred Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Tier 4 $$$$ Specialty Generally highest in copayment and cost. These drugs are sometimes used for complex and chronic conditions and may require special monitoring and handling.

Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.

M Authorized generic or cobranded product

PA Prior Authorization – Your doctor is required to give OptumRx more information to determine coverage.

PV Preventive drugs – May have coverage and no copayments when health care reform requirements are met.

PV* Preventive drugs – Available at $0 if Health Care Reform copay waiver is approved.

QL Quantity Limit – Medication may be limited to a certain quantity.

ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered.

3 Table of Contents Analgesics...... 5 Anesthetics...... 7 Anti-Addiction/Substance Abuse Treatment Agents...... 8 Antibacterials...... 8 ...... 11 Antidementia Agents...... 12 ...... 12 Antiemetics...... 14 ...... 14 Antigout Agents...... 15 Antimigraine Agents...... 15 Antimyasthenic Agents...... 15 Antimycobacterials...... 16 Antineoplastics...... 16 Antiparasitics...... 19 Antiparkinson Agents...... 20 ...... 21 Antivirals...... 21 Anxiolytics...... 23 Bipolar Agents...... 23 Blood Glucose Monitoring...... 24 Blood Glucose Regulators...... 24 Blood Products and Modifiers...... 26 Cardiovascular Agents...... 27 Central Nervous System Agents...... 31 Dental and Oral Agents...... 32 Dermatological Agents...... 32 Electrolytes/Minerals/Metals/Vitamins...... 33 Gastrointestinal Agents...... 36 Genetic or Disorder: Replacement, Modifiers, Treatment...... 37 Genitourinary Agents...... 38 Hormonal Agents, /Replacement/Modifying (Adrenal)...... 39 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)...... 41 Hormonal Agents, Stimulant/Replacement/Modifying ()...... 41 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)...... 41 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)...... 45 Hormonal Agents, Suppressant (Adrenal)...... 45 Hormonal Agents, Suppressant (Pituitary)...... 45 Hormonal Agents, Suppressant (Thyroid)...... 46 Immunological Agents...... 46 Inflammatory Bowel Disease Agents...... 48 Metabolic Bone Disease Agents...... 48 Miscellaneous Therapeutic Agents...... 49 Ophthalmic Agents...... 51 Otic Agents...... 53 Respiratory Tract/Pulmonary Agents...... 54 Skeletal Muscle Relaxants...... 56 Sleep Disorder Agents...... 56

4 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Analgesics diclofenac-misoprostol 1 acetaminophen diflunisal oral 1 1 intravenous solution ec- 1 bac 1 etodolac 1 -apap- etodolac er 1 oral capsule 50-325-40 1 fenoprofen oral mg 3 capsule 400 mg butalbital-apap-caffeine 1 fenoprofen calcium oral oral tablet 3 tablet butalbital-- 1 caffeine flurbiprofen oral 1 Anti- gnp aspirin low dose 1 PV inflammatory Drugs goodsense aspirin low 1 PV adult aspirin regimen 1 PV dose aspirin adult low 1 strength oral tablet 1 PV ibuprofen 1 delayed release ibuprofen oral 1 aspirin childrens 1 PV suspension aspirin ec low dose 1 PV inavix 1 aspirin ec low strength 1 PV indomethacin er 1 aspirin ec oral tablet indomethacin oral 1 delayed release 325 1 PV capsule 25 mg, 50 mg mg indomethacin 1 aspirin low dose 1 PV ketoprofen er 1 aspirin oral tablet 1 PV ketoprofen oral capsule 1 aspirin oral tablet 50 mg, 75 mg 1 PV delayed release ketorolac tromethamine 1 BAYER ASPIRIN 3 PV injection BAYER ASPIRIN EC ketorolac tromethamine 3 PV 1 LOW DOSE intramuscular celecoxib oral 1 QL ketorolac tromethamine 1 QL diclofenac potassium 1 oral meclofenamate sodium diclofenac sodium er 1 1 oral diclofenac sodium 1 QL external gel 1 % meloxicam oral 1 diclofenac sodium nabumetone oral 1 1 PA external solution naproxen oral tablet 1 diclofenac sodium oral 1 naproxen oral tablet 1 delayed release

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

5 Drug Name Drug Tier Notes Drug Name Drug Tier Notes naproxen sodium oral mitigo 1 1 tablet 275 mg, 550 mg er 1 PA; QL oxaprozin 1 morphine sulfate er 1 PA; QL piroxicam oral 1 beads qc aspirin low dose oral NUCYNTA ER 3 PA; QL 1 PV tablet delayed release OXYCONTIN 2 PA; QL salsalate oral 1 hcl er 1 PA; QL ST JOSEPH LOW hcl er 1 QL DOSE ORAL TABLET 3 PV tramadol hcl er DELAYED RELEASE 1 QL (biphasic) sulindac oral 1 XTAMPZA ER 2 PA; QL tolmetin sodium 1 Analgesics, Opioid Analgesics, Short-acting Long-acting acetaminophen- 1 QL 1 PA; QL transdermal acetaminophen- 1 QL 1 PA; QL codeine #2 bitartrate acetaminophen- 1 PA; QL 1 QL er codeine #3 hcl er 1 PA; QL acetaminophen- 1 QL HYSINGLA ER 2 PA; QL codeine #4 tartrate oral apap-caff- 3 PA; QL tablet 2 mg oral 1 PA; QL hcl injection 1 capsule methadone hcl intensol 1 ascomp-codeine 1 methadone hcl oral butalbital- 1 concentrate acetaminophen oral 1 capsule methadone hcl oral 1 solution butalbital- acetaminophen oral 1 methadone hcl oral 1 PA tablet 50-325 mg tablet butalbital-apap-caff-cod 1 methadone hcl oral 1 tablet soluble butalbital-apap-caffeine oral capsule 50-300-40 1 methadose oral 1 mg concentrate 10 mg/ml butalbital-asa-caff- methadose oral tablet 1 1 codeine soluble tartrate 1 methadose sugar-free 1 injection

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

6 Drug Name Drug Tier Notes Drug Name Drug Tier Notes butorphanol tartrate - 1 QL nasal acetaminophen oral codeine sulfate 1 QL tablet 10-325 mg, 2.5- 1 QL 325 mg, 5-325 mg, 7.5- duramorph 1 325 mg endocet 1 QL oxycodone-aspirin 1 QL fentanyl citrate buccal 1 PA; QL oxymorphone hcl 1 QL lozenge on a handle - hydrocodone- 1 QL 1 QL hcl acetaminophen tramadol hcl ir 1 QL hydrocodone-ibuprofen 1 QL tramadol- 1 QL hydromorphone hcl acetaminophen injection solution 1 1 mg/ml, 2 mg/ml, 4 Anesthetics mg/ml Local Anesthetics hydromorphone hcl oral 1 QL ethyl chloride 1 hydromorphone hcl pf 1 glydo 1 morphine sulfate lidocaine external 1 (concentrate) oral ointment 5 % 1 QL solution 100 mg/5ml, lidocaine external patch 1 20 mg/ml 5 % morphine sulfate (pf) lidocaine hcl (pf) 1 1 injection injection solution 2 % morphine sulfate (pf) lidocaine hcl external 1 intravenous solution 2 1 solution mg/ml, 4 mg/ml lidocaine hcl injection 1 morphine sulfate solution 2 % injection solution 2 1 lidocaine hcl mg/ml, 4 mg/ml 1 mouth/throat morphine sulfate oral 1 QL lidocaine hcl oxycodone hcl oral 1 1 QL urethral/mucosal capsule lidocaine viscous hcl 1 oxycodone hcl oral lidocaine-prilocaine concentrate 100 1 QL 1 mg/5ml external cream oxycodone hcl oral LIDOCAINE- 1 QL TETRACAINE solution 3 EXTERNAL CREAM 7- oxycodone hcl oral 1 QL 7 % tablet

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

7 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Anti- nicotine polacrilex 1 PV; QL Addiction/Substance mouth/throat Abuse Treatment nicotine step 1 1 PV; QL Agents nicotine step 2 1 PV; QL Deterrents/Anti- nicotine step 3 1 PV; QL craving NICOTROL 3 ST; PV; QL acamprosate calcium 1 NICOTROL NS 3 ST; PV; QL disulfiram oral 1 Antibacterials hcl oral 1 Aminoglycosides VIVITROL 4 amikacin sulfate 1 Opioid Dependence injection Treatments gentamicin in saline 1 buprenorphine hcl gentamicin sulfate 1 1 injection external buprenorphine hcl gentamicin sulfate 1 QL 1 sublingual injection buprenorphine hcl- sulfate oral 1 1 QL naloxone hcl paromomycin sulfate 1 Opioid Reversal oral Agents streptomycin sulfate 1 naloxone hcl injection 1 intramuscular NARCAN 2 tobramycin sulfate 1 Smoking Cessation injection Agents Antbacterials, Other hcl er 1 1 PV; QL (smoking det) Antibacterials, Other CHANTIX 3 ST; PV; QL ALTABAX 3 CHANTIX intramuscular 1 CONTINUING MONTH 3 ST; PV; QL chloramphenicol sod PAK 1 succinate CHANTIX STARTING 3 ST; PV; QL MONTH PAK clindamycin hcl oral 1 clindamycin palmitate goodsense nicotine 1 mouth/throat lozenge 4 1 PV; QL hcl mg clindamycin phosphate 1 habitrol 1 PV; QL in d5w clindamycin phosphate NICORETTE 1 MOUTH/THROAT 3 PV; QL injection GUM 2 MG

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

8 Drug Name Drug Tier Notes Drug Name Drug Tier Notes clindamycin phosphate hcl in 1 vaginal dextrose intravenous colistimethate sodium solution 1-5 gm/200ml- 1 1 (cba) %, 500-5 mg/100ml-%, 750-5 mg/150ml-% CORTISPORIN 3 vancomycin hcl in nacl 1 intravenous solution 1- 1 0.9 gm/200ml-%, 500- 1 tromethamine 0.9 mg/100ml-% tincture external VANCOMYCIN HCL IN 1 tincture 2 % NACL SOLUTION 750- 3 lincomycin hcl injection 1 0.9 MG/150ML-% INTRAVENOUS linezolid in sodium 1 chloride vancomycin hcl in nacl solution 750-0.9 1 linezolid intravenous 1 mg/150ml-% linezolid oral 1 QL intravenous mafenide acetate vancomycin hcl 1 1 external intravenous methenamine hippurate 1 vancomycin hcl oral 1 metronidazole in nacl 1 XIFAXAN 3 PA metronidazole oral 1 ZYVOX INTRAVENOUS metronidazole vaginal 1 3 SOLUTION 200 mupirocin external 1 MG/100ML NEO-SYNALAR 3 Beta-lactam, EXTERNAL CREAM nitrofurantoin 1 1 nitrofurantoin 1 cefaclor er 1 macrocrystal 1 nitrofurantoin sodium monohydrate 1 1 macrocrystals injection b sulfate cefazolin sodium 1 injection intravenous solution 1 reconstituted PRIMSOL 3 cefazolin sodium- sulfadiazine dextrose intravenous 1 1 external solution 1-4 gm/50ml- ssd 1 %, 2-4 gm/100ml-% tinidazole oral 1 trimethoprim oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

9 Drug Name Drug Tier Notes Drug Name Drug Tier Notes cefazolin sodium- sodium 1 dextrose intravenous 1 ampicillin- 1 solution reconstituted sodium 1 AUGMENTIN ORAL hcl 1 SUSPENSION 3 cefepime-dextrose 1 RECONSTITUTED 125-31.25 MG/5ML 1 BICILLIN L-A 3 sodium 1 sodium 1 disodium 1 sodium 1 cefotetan disodium- 1 dextrose sodium 1 sodium 1 g potassium 1 proxetil 1 penicillin g sodium 1 1 penicillin v potassium 1 and sod- 1 dextrose so intravenous solution ceftazidime injection 1 reconstituted 2.25 (2- 1 sodium in 0.25) gm, 3.375 (3- 1 dextrose 0.375) gm, 4.5 (4-0.5) ceftriaxone sodium gm, 40.5 (36-4.5) gm 1 injection ceftriaxone sodium sodium 1 1 intravenous -cilastatin 1 ceftriaxone sodium- 1 1 dextrose axetil 1 azithromycin 1 cephalexin 1 intravenous tazicef injection 1 azithromycin oral 1 tazicef intravenous 1 er 1 solution reconstituted clarithromycin oral 1 Beta-lactam, DIFICID ORAL 3 TABLET 1 base 1 amoxicillin-potassium 1 erythromycin clavulanate er 1 ethylsuccinate oral amoxicillin-potassium 1 clavulanate oral erythromycin oral 1 ampicillin 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

10 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ZITHROMAX ORAL doxycycline 3 1 PACKET monohydrate oral tablet Quinolones MINOCIN 3 BAXDELA ORAL 3 INTRAVENOUS CIPRO ORAL hcl oral 1 SUSPENSION 3 mondoxyne nl oral 1 RECONSTITUTED capsule 100 mg hcl oral 1 morgidox oral 1 ciprofloxacin in d5w 1 tetracycline hcl oral 1 in d5w 1 Anticonvulsants levofloxacin Anticonvulsants, 1 intravenous Other levofloxacin oral 1 BRIVIACT ORAL 3 ST moxifloxacin hcl in nacl 1 EPIDIOLEX 4 PA moxifloxacin hcl oral 1 levetiracetam er 1 oral 1 levetiracetam in nacl 1 Sulfonamides levetiracetam 1 sulfadiazine oral 1 intravenous sulfamethoxazole- levetiracetam oral 1 1 trimethoprim roweepra 1 sulfatrim pediatric 1 Calcium Channel Tetracyclines Modifying Agents avidoxy 1 CELONTIN 3 demeclocycline hcl 1 ethosuximide oral 1 doxy 100 1 zonisamide oral 1 doxycycline hyclate Gamma-aminobutyric 1 intravenous Acid (GABA) Augmenting Agents doxycycline hyclate oral 1 capsule 1 PA doxycycline hyclate oral DIACOMIT 4 PA 1 tablet 100 mg, 20 mg rectal 1 QL doxycycline gabapentin oral 1 monohydrate oral 1 sodium 1 capsule 100 mg, 50 mg injection doxycycline oral 1 monohydrate oral 1 phenobarbital sodium suspension 1 reconstituted injection

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

11 Drug Name Drug Tier Notes Drug Name Drug Tier Notes oral 1 oral 1 tiagabine hcl 1 phenytoin sodium 1 sodium extended 1 intravenous phenytoin sodium 1 valproic acid oral 1 injection Glutamate Reducing rufinamide 1 PA Agents VIMPAT ORAL 3 1 Antidementia Agents FYCOMPA 3 Antidementia Agents, lamotrigine er 1 Other lamotrigine oral 1 NAMZARIC ORAL CAPSULE EXTENDED lamotrigine starter kit- 2 QL 1 RELEASE 24 HOUR blue 14-10 MG lamotrigine starter kit- 1 green Inhibitors lamotrigine starter kit- 1 hcl 1 orange 1 subvenite 1 hydrobromide subvenite starter kit- galantamine 1 1 blue hydrobromide er subvenite starter kit- 1 1 green rivastigmine tartrate 1 subvenite starter kit- 1 orange N-methyl-D-aspartate (NMDA) er 1 Antagonist topiramate oral 1 hcl er 1 QL Sodium Channel memantine hcl oral 1 Agents NAMZARIC ORAL BANZEL 3 PA CAPSULE EXTENDED er 1 RELEASE 24 HOUR 2 QL carbamazepine oral 1 21-10 MG, 28-10 MG, 7-10 MG DILANTIN ORAL 3 CAPSULE 30 MG Antidepressants epitol 1 Antidepressants, Other fosphenytoin sodium 1 APLENZIN 3 ST; QL 1 bupropion hcl er (sr) 1 QL phenytoin infatabs 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

12 Drug Name Drug Tier Notes Drug Name Drug Tier Notes bupropion hcl er (xl) hcl oral tablet 1 oral tablet extended 1 QL fluvoxamine maleate 1 release 24 hour 150 mg, 300 mg fluvoxamine maleate er 1 QL bupropion hcl oral 1 hcl 1 - hcl 3 1 hcl 1 oral 1 paroxetine hcl er 1 -fluoxetine paroxetine mesylate 1 QL 1 QL hcl PAXIL ORAL 2 ST - SUSPENSION 1 amitriptyline sertraline hcl oral 1 hcl oral 1 Inhibitors TRINTELLIX 3 ST; QL EMSAM 3 QL venlafaxine hcl 1 MARPLAN 3 venlafaxine hcl er oral phenelzine sulfate oral 1 capsule extended 1 tranylcypromine sulfate 1 release 24 hour SSRI/SNRI (Selective venlafaxine hcl er oral Reuptake tablet extended release 1 Inhibitors/Serotonin 24 hour 225 mg and VIIBRYD 3 QL Reuptake Inhibitors) VIIBRYD STARTER citalopram 3 QL 1 PACK hydrobromide Tricyclics desvenlafaxine 1 QL succinate er amitriptyline hcl oral 1 duloxetine hcl oral 1 QL 1 escitalopram 1 hcl oral 1 FETZIMA 3 ST; QL hcl oral 1 hcl oral FETZIMA 3 ST; QL 1 capsule fluoxetine hcl (pmdd) 1 doxepin hcl oral fluoxetine hcl oral 1 1 concentrate capsule hcl oral 1 fluoxetine hcl oral capsule delayed 1 QL imipramine pamoate 1 release hcl oral 1 fluoxetine hcl oral hcl 1 1 solution

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

13 Drug Name Drug Tier Notes Drug Name Drug Tier Notes maleate hcl oral 1 1 QL oral tablet 24 mg Antiemetics ondansetron hcl oral 1 Antiemetics, Other tablet 4 mg, 8 mg compro 1 ondansetron odt 1 hcl 1 1 injection Antifungals injection 1 ABELCET 3 hcl oral tablet AMBISOME 3 1 12.5 mg, 25 mg acetate 1 meclizine hcl oral tablet 1 ciclodan 1 chewable external 1 hcl 1 ciclopirox olamine injection 1 external metoclopramide hcl 1 oral external 1 clotrimazole perphenazine oral 1 1 mouth/throat 1 clotrimazole- prochlorperazine 1 1 edisylate injection CRESEMBA 3 prochlorperazine 1 nitrate maleate oral 1 external 1 in sodium 1 Emetogenic Therapy chloride Adjuncts fluconazole oral 1 AKYNZEO ORAL 3 QL oral 1 ANZEMET 3 QL microsize 1 aprepitant 1 QL oral dronabinol 1 PA; QL griseofulvin 1 fosaprepitant ultramicrosize 1 dimeglumine GYNAZOLE-1 3 hcl 1 oral 1 PA intravenous KERYDIN 3 PA granisetron hcl oral 1 QL external ondansetron hcl 1 1 cream injection ketoconazole external ondansetron hcl oral 1 1 QL shampoo solution ketoconazole oral 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

14 Drug Name Drug Tier Notes Drug Name Drug Tier Notes sodium 1 Prophylactic 3 1 AIMOVIG hcl 1 SUBCUTANEOUS SOLUTION AUTO- 2 PA; QL nyamyc 1 INJECTOR 140 external 1 MG/ML, 70 MG/ML nystatin mouth/throat 1 EMGALITY 2 PA; QL nystatin oral 1 EMGALITY (300 MG 2 PA; QL nystatin- 1 DOSE) nystop 1 Serotonin (5-HT) 1b/1d Receptor nitrate 3 OXISTAT EXTERNAL 3 malate 1 QL LOTION hydrobromide 1 QL 1 hcl 1 QL 1 PA benzoate 1 QL hcl oral 1 QL nasal 1 QL 1 sumatriptan succinate 1 QL 1 oral intravenous sumatriptan succinate 1 QL voriconazole oral 1 refill Antigout Agents sumatriptan succinate 1 QL oral 1 subcutaneous allopurinol sodium 1 sumatriptan-naproxen 3 QL colchicine oral tablet 1 sodium colchicine-probenecid 1 3 ST; QL NASAL 1 ST zolmitriptan oral 1 QL probenecid 1 ZOMIG NASAL 3 ST; QL Antimigraine Agents Antimyasthenic Agents 1 PA; QL Parasympathomimeti mesylate injection cs dihydroergotamine 1 PA; QL GUANIDINE HCL 3 mesylate nasal -caffeine 1 methylsulfate 1 intravenous solution 10 mg/10ml, 5 mg/10ml

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

15 Drug Name Drug Tier Notes Drug Name Drug Tier Notes pyridostigmine LEUKERAN 2 1 er MATULANE 4 pyridostigmine bromide 1 melphalan 4 oral melphalan hcl 4 Antimycobacterials MYLERAN 2 Antimycobacterials, Other oxaliplatin 4 oral 1 paraplatin 4 TEMODAR rifabutin 1 4 INTRAVENOUS Antituberculars temozolomide 4 PA CAPASTAT SULFATE 3 ZANOSAR 4 oral 1 ZEPZELCA 4 PA ethambutol hcl oral 1 Antiandrogens injection 1 abiraterone acetate 4 PA isoniazid oral 1 bicalutamide 1 PASER 3 flutamide 1 PRIFTIN 3 nilutamide 4 pyrazinamide oral 1 XTANDI 4 PA rifampin intravenous 1 Antiangiogenic rifampin oral 1 Agents SIRTURO 3 POMALYST 4 PA TRECATOR 3 REVLIMID 4 PA Antineoplastics THALOMID 4 PA Alkylating Agents Antiestrogens/Modifie BENDEKA 4 PA rs busulfan 4 EMCYT 3 carboplatin 4 fulvestrant 4 carmustine 4 SOLTAMOX 3 PV* cisplatin intravenous tamoxifen citrate oral 4 1 solution tablet 10 mg cyclophosphamide tamoxifen citrate oral 4 1 PV* injection tablet 20 mg cyclophosphamide oral 1 toremifene citrate 1 dacarbazine 4 Antimetabolites GLEOSTINE 4 ALIMTA 4 ifosfamide 4 capecitabine 4 PA

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

16 Drug Name Drug Tier Notes Drug Name Drug Tier Notes cladribine 4 FLUOROURACIL clofarabine 4 EXTERNAL CREAM 2 0.5 % cytarabine 4 fluorouracil external 1 cytarabine (pf) 4 cream 5 % decitabine 4 PA fluorouracil external 4 DROXIA 3 solution floxuridine injection 4 HALAVEN 4 PA fludarabine phosphate 4 idarubicin hcl 4 fluorouracil intravenous 4 irinotecan hcl 4 FOLOTYN 4 PA ISTODAX (OVERFILL) 4 PA gemcitabine hcl 4 IXEMPRA KIT 4 hydroxyurea oral 1 leucovorin calcium 1 mercaptopurine oral 1 injection NIPENT 4 leucovorin calcium oral 1 TABLOID 4 levoleucovorin calcium 4 levoleucovorin calcium Antineoplastics, 4 Other pf ABRAXANE 4 LONSURF 4 PA adriamycin 4 MARQIBO 4 ARRANON 4 mitomycin intravenous 4 arsenic trioxide mitoxantrone hcl 4 PA 4 intravenous mutamycin 4 azacitidine 4 NINLARO 4 PA bleomycin sulfate 4 ONCASPAR 4 dactinomycin 4 ONIVYDE 4 daunorubicin hcl 4 ONUREG 4 PA dexrazoxane hcl 4 paclitaxel 4 diclofenac sodium PICATO 3 ST 1 ST; QL external gel 3 % PIQRAY 4 PA docetaxel 4 PROLEUKIN 4 doxorubicin hcl 4 ROZLYTREK 4 PA doxorubicin hcl 4 SYNRIBO 4 PA liposomal teniposide 4 epirubicin hcl 4 TOTECT 4 ETHYOL 4 VELCADE 4 PA FLUOROPLEX 3

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

17 Drug Name Drug Tier Notes Drug Name Drug Tier Notes vinblastine sulfate 4 everolimus oral tablet 4 PA; QL vincristine sulfate 4 2.5 mg, 5 mg, 7.5 mg vinorelbine tartrate 4 FARYDAK 4 PA VYXEOS 4 PA GILOTRIF 4 PA; QL ZALTRAP 4 PA IBRANCE 4 PA ZOLINZA 4 PA ICLUSIG ORAL TABLET 10 MG, 15 4 PA; QL Aromatase Inhibitors, MG 3rd Generation ICLUSIG ORAL anastrozole oral 1 PV* TABLET 30 MG, 45 4 PA exemestane 1 PV* MG letrozole oral 1 imatinib mesylate 4 PA Enzyme Inhibitors IMBRUVICA 4 PA etoposide intravenous 4 INLYTA 4 PA etoposide oral 4 JAKAFI ORAL TABLET 4 PA; QL HYCAMTIN ORAL 4 10 MG KYPROLIS 4 PA JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 4 PA RUBRACA 4 PA 5 MG toposar 4 JEVTANA 4 PA topotecan hcl 4 KOSELUGO 4 PA Molecular Target lapatinib ditosylate 4 PA Inhibitors LENVIMA ORAL AFINITOR DISPERZ 4 PA CAPSULE THERAPY BELEODAQ 4 PA PACK 10 & 4 MG, 10 BOSULIF 4 PA MG, 10 MG & 2 X 4 4 PA MG, 2 X 10 MG, 2 X 10 CABOMETYX 4 PA MG & 4 MG, 2 X 4 MG, CAPRELSA ORAL 3 X 4 MG, 4 MG 4 PA; QL TABLET 100 MG LYNPARZA 4 PA CAPRELSA ORAL 4 PA MEKINIST 4 PA TABLET 300 MG NEXAVAR 4 PA COMETRIQ 4 PA QINLOCK 4 PA COTELLIC 4 PA RYDAPT 4 PA ERIVEDGE 4 PA SPRYCEL 4 PA erlotinib hcl oral tablet 4 PA 100 mg, 150 mg STIVARGA 4 PA erlotinib hcl oral tablet SUTENT 4 PA 4 PA; QL 25 mg TAFINLAR 4 PA

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

18 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TAGRISSO ORAL OPDIVO 4 PA 4 PA; QL TABLET 40 MG PADCEV 4 PA TAGRISSO ORAL 4 PA PERJETA 4 PA TABLET 80 MG POLIVY 4 PA TASIGNA 4 PA RITUXAN 4 PA TUKYSA 4 PA RITUXAN HYCELA 4 PA TURALIO 4 PA RUXIENCE 4 PA TYKERB 4 PA TECENTRIQ 4 PA VENCLEXTA 4 PA TRAZIMERA 4 PA VENCLEXTA 4 PA STARTING PACK UNITUXIN 4 PA VOTRIENT 4 PA YERVOY 4 PA XALKORI 4 PA ZIRABEV 4 PA ZELBORAF 4 PA Retinoids ZYDELIG 4 PA bexarotene 4 PA ZYKADIA 4 PA PANRETIN 3 TARGRETIN Monoclonal 4 PA Antibody/Antibody- EXTERNAL Drug Conjugate tretinoin oral 4 ADCETRIS 4 PA Treatment Adjuncts ARZERRA 4 PA ELITEK 4 AVASTIN 4 PA mesna 4 BAVENCIO 4 PA MESNEX ORAL 4 BLINCYTO 4 PA Antiparasitics CYRAMZA 4 PA Anthelmintics DARZALEX 4 PA albendazole oral 1 PA EMPLICITI 4 PA EMVERM 2 ENHERTU 4 PA external 1 ERBITUX 4 PA ivermectin oral 1 GAZYVA 4 PA praziquantel oral 1 HERCEPTIN 4 PA SKLICE 3 HERCEPTIN Antiprotozoals 4 PA HYLECTA ALINIA 2 KADCYLA 4 PA oral 1 KANJINTI 4 PA atovaquone-proguanil 1 MVASI 4 PA hcl

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

19 Drug Name Drug Tier Notes Drug Name Drug Tier Notes BENZNIDAZOLE 3 mesylate 1 chloroquine phosphate oral 1 QL oral NEUPRO 3 ST COARTEM 3 1 hydroxychloroquine dihydrochloride 1 QL sulfate oral pramipexole 1 IMPAVIDO 3 dihydrochloride er mefloquine hcl 1 hcl 1 nitazoxanide 1 ropinirole hcl er 1 isethionate 1 Precursors and/or L- primaquine phosphate 1 Decarboxylase pyrimethamine oral 4 PA Inhibitors sulfate oral 1 PA -levodopa er Pediculicides/Scabici oral tablet extended 1 des release 50-200 mg crotan 1 carbidopa-levodopa oral tablet 10-100 mg, 1 3 25-250 mg malathion 1 carbidopa-levodopa permethrin external 1 oral tablet dispersible 1 spinosad 1 25-100 mg sulfurated lime 1 Dopamine Precursors/L-Amino Antiparkinson Agents Acid Decarboxylase Inhibitors benztropine mesylate 1 carbidopa oral 1 hcl 1 carbidopa-levodopa er Antiparkinson oral tablet extended 1 Agents, Other release 25-100 mg carbidopa-levodopa hcl oral 1 1 oral tablet 25-100 mg carbidopa-levodopa- oral tablet carbidopa-levodopa 1 12.5-50-200 mg, 18.75- oral tablet dispersible 1 75-200 mg 10-100 mg, 25-250 mg entacapone 1 carbidopa-levodopa- entacapone oral tablet 1 25-100-200 mg, 31.25- 1 Dopamine Agonists 125-200 mg, 37.5-150- APOKYN 4 PA; QL 200 mg, 50-200-200 mg

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20 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Monoamine Oxidase er 1 QL B (MAO-B) Inhibitors fumarate 1 QL mesylate oral 1 quetiapine fumarate er 1 QL hcl oral 1 REXULTI 3 QL Antipsychotics RISPERDAL CONSTA 3 1st 1 QL Generation/Typical SAPHRIS 2 QL hcl 1 injection hcl 1 QL chlorpromazine hcl oral 1 ziprasidone mesylate 1 ZYPREXA RELPREVV 3 1 decanoate injection Treatment-Resistant fluphenazine hcl 1 1 QL decanoate Antivirals 1 intramuscular Anti-cytomegalovirus haloperidol lactate 1 (CMV) Agents haloperidol oral 1 cidofovir intravenous 1 succinate 1 ganciclovir sodium 1 hcl 1 valganciclovir hcl 1 1 Anti-hepatitis B (HBV) hcl oral 1 Agents thiothixene 1 adefovir dipivoxil 4 BARACLUDE ORAL hcl 1 4 QL SOLUTION 2nd Generation/Atypical entecavir 4 QL EPIVIR HBV ORAL ABILIFY MAINTENA 3 4 SOLUTION 1 QL lamivudine oral tablet 4 maleate 1 QL 100 mg FANAPT 3 ST; QL VEMLIDY 4 FANAPT TITRATION 3 ST; QL Anti- (HCV) PACK Agents INVEGA SUSTENNA 3 EPCLUSA 4 PA; QL INVEGA TRINZA 3 HARVONI 4 PA; QL LATUDA 3 QL MAVYRET 4 PA; QL olanzapine 1 PEGASYS 4 PA intramuscular oral 4 olanzapine oral 1 QL

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21 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ZEPATIER 4 PA; QL SYMFI 2 Anti-hepatitis C (HCV) SYMFI LO 2 Agents, Other Anti-HIV Agents, INTRON A 4 PA and Antiherpetic Agents Reverse Transcriptase acyclovir external 1 Inhibitors (NRTI) acyclovir oral 1 abacavir sulfate 1 acyclovir sodium 1 abacavir sulfate- 1 DENAVIR 3 lamivudine famciclovir oral 1 abacavir-lamivudine- 1 valacyclovir hcl oral 1 QL zidovudine Anti-HIV Agents, CIMDUO 2 Integrase Inhibitors DESCOVY 3 PA; PV* (INSTI) emtricitabine 1 BIKTARVY 3 emtricitabine-tenofovir GENVOYA 3 df oral tablet 100-150 1 ISENTRESS 2 mg, 133-200 mg, 167- 250 mg ISENTRESS HD 2 emtricitabine-tenofovir JULUCA 2 df oral tablet 200-300 1 PV* STRIBILD 3 mg TIVICAY 2 EMTRIVA 2 TIVICAY PD 2 lamivudine oral solution 1 TYBOST 2 lamivudine oral tablet 1 Anti-HIV Agents, Non- 150 mg, 300 mg nucleoside Reverse lamivudine-zidovudine 1 Transcriptase ODEFSEY 3 Inhibitors (NNRTI) RETROVIR 2 COMPLERA 2 INTRAVENOUS EDURANT 2 stavudine 1 1 tenofovir disoproxil 1 PV* efavirenz-emtricitab- fumarate 1 tenofovir TRIUMEQ 2 efavirenz-lamivudine- 1 TRUVADA 2 tenofovir VIREAD ORAL 2 INTELENCE 2 POWDER nevirapine 1 nevirapine er 1

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22 Drug Name Drug Tier Notes Drug Name Drug Tier Notes VIREAD ORAL hcl 1 TABLET 150 MG, 200 2 Anxiolytics MG, 250 MG Anxiolytics, Other zidovudine 1 hcl oral 1 Anti-HIV Agents, hcl Other 1 intramuscular FUZEON 2 hydroxyzine hcl oral 1 RUKOBIA 2 hydroxyzine pamoate 1 SELZENTRY 2 PA oral TROGARZO 3 PA Anti-HIV Agents, er 1 QL Protease Inhibitors alprazolam intensol 1 QL APTIVUS 2 alprazolam oral tablet 1 QL atazanavir sulfate 1 alprazolam xr 1 QL CRIXIVAN 2 chlordiazepoxide hcl 1 QL EVOTAZ 2 oral 1 QL fosamprenavir calcium 1 1 QL INVIRASE 2 dipotassium KALETRA ORAL 2 diazepam injection 1 TABLET diazepam intensol 1 LEXIVA ORAL 2 diazepam SUSPENSION 1 intramuscular lopinavir- 1 diazepam oral 1 NORVIR ORAL 2 PACKET 1 QL NORVIR ORAL injection 1 2 SOLUTION lorazepam intensol 1 QL PREZCOBIX 2 lorazepam oral 1 QL PREZISTA 2 concentrate 2 mg/ml REYATAZ ORAL lorazepam oral tablet 1 QL 2 PACKET 1 QL ritonavir 1 1 QL VIRACEPT 2 Bipolar Agents Anti- Agents Mood Stabilizers phosphate divalproex sodium er 1 1 QL oral divalproex sodium oral 1 RELENZA DISKHALER 3 QL lithium 1

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23 Drug Name Drug Tier Notes Drug Name Drug Tier Notes lithium carbonate er 1 INPEN 100-GREY- 3 lithium carbonate oral 1 NOVO INPEN 100-PINK- Blood Glucose 3 Monitoring LILLY INPEN 100-PINK- ACCU-CHEK 3 FASTCLIX LANCET 2 NOVO KIT KETOSTIX 3 ACCU-CHEK LANCETS 2 SOFTCLIX LANCET 2 NOVOPEN ECHO 3 DEVICE KIT ONETOUCH DELICA CEQUR SIMPLICITY 3 3 LANCING DEV 2U ONETOUCH DELICA 3 CHEMSTRIP UGK 3 PLUS LANCING CONTOUR CONTROL 2 Blood Glucose SOLUTION Regulators CONTOUR MONITOR 2 Antidiabetic Agents DEVICE acarbose oral 1 CONTOUR MONITOR 2 BYDUREON BCISE KIT W/DEVICE 2 ST; QL AUTOINJECTOR CONTOUR NEXT 2 CONTROL SOLUTION BYETTA 10 MCG PEN 2 ST; QL CONTOUR NEXT EZ BYETTA 5 MCG PEN 2 ST; QL 2 KIT W/DEVICE FARXIGA 2 ST CONTOUR NEXT LINK 2 glimepiride 1 CONTOUR NEXT glipizide er 1 MONITOR KIT 2 glipizide ir 1 W/DEVICE glipizide xl 1 CONTOUR NEXT ONE 2 KIT glipizide-metformin hcl 1 CONTOUR NEXT glyburide micronized 1 2 QL TEST STRIPS glyburide oral 1 CONTOUR TEST glyburide-metformin 1 2 QL STRIPS GLYXAMBI 2 ST INPEN 100-BLUE- 3 JANUMET 2 ST LILLY JANUMET XR 2 ST INPEN 100-BLUE- 3 NOVO JANUVIA 2 ST INPEN 100-GRAY- JARDIANCE 2 ST 3 LILLY JENTADUETO 2 ST JENTADUETO XR 2 ST

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24 Drug Name Drug Tier Notes Drug Name Drug Tier Notes metformin hcl er 1 HUMALOG VIAL 2 metformin hcl ir 1 HUMULIN 70/30 2 miglitol 1 KWIKPEN nateglinide 1 HUMULIN 70/30 VIAL 2 OZEMPIC 2 ST; QL HUMULIN N KWIKPEN 2 pioglitazone hcl 1 HUMULIN N VIAL 2 pioglitazone hcl- HUMULIN R U-500 1 2 glimepiride KWIKPEN pioglitazone hcl- HUMULIN R U-500 1 2 metformin hcl VIAL repaglinide 1 HUMULIN R VIAL 2 SYNJARDY 2 ST LANTUS SOLOSTAR 2 SYNJARDY XR 2 ST LANTUS U-100 VIAL 2 LEVEMIR U-100 TRADJENTA 2 ST 2 FLEXTOUCH TRULICITY 2 ST; QL LEVEMIR U-100 VIAL 2 VICTOZA 2 ST; QL NOVOLIN 70/30 3 XIGDUO XR 2 ST FLEXPEN Glycemic Agents NOVOLIN 70/30 3 oral 1 FLEXPEN RELION glucagon emergency kit NOVOLIN 70/30 1 3 1 mg injection 1 mg RELION GLUCAGON NOVOLIN 70/30 VIAL 3 EMERGENCY KIT 1 2 Made by Lilly NOVOLIN N FLEXPEN 3 MG INJECTION 1 MG NOVOLIN N FLEXPEN GLUCAGON Made by 3 2 RELION EMERGENCY KIT Fresenius NOVOLIN N RELION 3 Insulins NOVOLIN N VIAL 3 HUMALOG KWIKPEN 2 NOVOLIN R FLEXPEN 3 HUMALOG MIX 50/50 2 NOVOLIN R FLEXPEN KWIKPEN 3 RELION HUMALOG MIX 50/50 2 VIAL NOVOLIN R RELION 3 HUMALOG MIX 75/25 NOVOLIN R VIAL 3 2 KWIKPEN NOVOLOG FLEXPEN 3 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 2 3 VIAL FLEXPEN HUMALOG U-100 NOVOLOG MIX 70/30 2 3 JUNIOR KWIKPEN VIAL

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25 Drug Name Drug Tier Notes Drug Name Drug Tier Notes NOVOLOG PENFILL 3 ZONTIVITY 3 NOVOLOG U-100 VIAL 3 Blood Formation TOUJEO MAX Modifiers 2 SOLOSTAR ADAKVEO 4 PA TOUJEO SOLOSTAR 2 anagrelide hcl 1 TRESIBA 3 ARANESP (ALBUMIN 4 PA TRESIBA FREE) 3 FLEXTOUCH MOZOBIL 4 PA; QL Blood Products and NEULASTA 4 PA Modifiers NEULASTA ONPRO 4 PA CEPROTIN 4 NIVESTYM 4 PA SOLIRIS 4 PA PROMACTA 4 PA REBLOZYL 4 PA 1 RETACRIT 4 PA 1 Hemostasis Agents trifluoroacetate ADVATE 4 ELIQUIS 2 QL ALPHANATE 4 ELIQUIS DVT/PE 2 QL aminocaproic acid STARTER PACK 1 intravenous 1 QL aminocaproic acid oral 1 sodium 1 QL BENEFIX 4 (porcine) in nacl intravenous 1 COAGADEX 4 solution CORIFACT 4 heparin sod (porcine) in ELOCTATE 4 1 d5w FEIBA 4 heparin sodium 1 HEMLIBRA 4 (porcine) HEMOFIL M 4 heparin sodium 1 (porcine) pf HUMATE-P 4 jantoven 1 KOATE 4 PRADAXA 2 QL KOATE-DVI 4 SAVAYSA 3 QL KOGENATE FS 4 THROMBATE III 4 KOVALTRY 4 sodium oral 1 NOVOEIGHT 4 XARELTO 2 QL NOVOSEVEN RT 4 XARELTO STARTER NUWIQ 4 2 QL PACK OBIZUR 4

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26 Drug Name Drug Tier Notes Drug Name Drug Tier Notes PROFILNINE 4 mesylate 1 sulfate injection 1 intravenous hcl oral 1 RECOMBINATE 4 Angiotensin II RIASTAP 4 Receptor Antagonists RIXUBIS 4 candesartan cilexetil 1 tranexamic acid oral 1 irbesartan 1 VONVENDI 4 losartan potassium oral 1 olmesartan medoxomil XYNTHA 4 1 oral XYNTHA SOLOFUSE 4 telmisartan 1 Modifying Agents valsartan 1 aspirin- er 1 Angiotensin- converting Enzyme BRILINTA 2 (ACE) Inhibitors CABLIVI 4 PA; QL benazepril hcl oral 1 1 captopril oral 1 bisulfate 1 enalapril maleate oral 1 oral enalaprilat 1 dipyridamole oral 1 fosinopril sodium 1 1 lisinopril oral 1 prasugrel hcl 1 moexipril hcl 1 Cardiovascular Agents perindopril erbumine 1 Alpha- quinapril hcl 1 Agonists ramipril 1 1 trandolapril 1 clonidine hcl oral 1 Antiarrhythmics hcl 1 intravenous 1 solution 12 mg/4ml, 6 1 mg/2ml hcl 1 hcl 1 Alpha-adrenergic disopyramide Blocking Agents 1 phosphate mesylate 1 oral dofetilide 1 hcl flecainide acetate 1 1 oral ibutilide fumarate 1

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27 Drug Name Drug Tier Notes Drug Name Drug Tier Notes lidocaine hcl (cardiac) tartrate 1 intravenous solution intravenous 1 prefilled syringe 100 metoprolol tartrate oral 1 mg/5ml, 50 mg/5ml 1 lidocaine hcl (cardiac) 1 pf hcl er 1 propranolol hcl lidocaine in d5w 1 intravenous solution 4- intravenous 1 5 mg/ml-%, 8-5 mg/ml- propranolol hcl oral 1 % maleate oral 1 mexiletine hcl oral 1 Calcium Channel procainamide hcl Blocking Agents 1 injection amlodipine besylate 1 hcl 1 oral propafenone hcl er 1 cartia xt 1 gluconate er 1 hcl er 1 quinidine sulfate 1 diltiazem hcl er beads 1 sorine 1 diltiazem hcl er coated 1 hcl (af) 1 beads diltiazem hcl sotalol hcl oral 1 1 intravenous Beta-adrenergic Blocking Agents diltiazem hcl oral 1 hcl oral 1 dilt-xr 1 oral 1 felodipine er 1 hcl oral 1 matzim la 1 hcl fumarate oral 1 1 intravenous BYSTOLIC 2 nifedipine er 1 1 nifedipine er osmotic 1 carvedilol phosphate er 1 release esmolol hcl intravenous 1 nimodipine oral 1 solution 100 mg/10ml nisoldipine er 1 esmolol hcl-sodium 1 chloride taztia xt 1 hcl tiadylt er 1 1 intravenous solution hcl er 1 labetalol hcl oral 1 verapamil hcl 1 metoprolol succinate er 1 intravenous verapamil hcl oral 1

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28 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Cardiovascular sulfate 1 Agents, Other intravenous solution aliskiren fumarate 1 epinephrine pf 1 alprostadil injection 1 fosinopril sodium-hctz 1 amiloride- irbesartan- 1 1 hydrochlorothiazide amlodipine besylate- lisinopril- 1 1 benazepril hcl hydrochlorothiazide amlodipine besylate- losartan potassium-hctz 1 1 valsartan methyldopa- 1 amlodipine-atorvastatin 1 hydrochlorothiazide amlodipine-olmesartan 1 metoprolol- 1 amlodipine-valsartan- hydrochlorothiazide 1 hctz metyrosine 1 atenolol-chlorthalidone 1 milrinone lactate 1 benazepril- milrinone lactate in 1 1 hydrochlorothiazide dextrose bisoprolol- norepinephrine 1 1 hydrochlorothiazide bitartrate intravenous candesartan cilexetil- olmesartan medoxomil- 1 1 hctz hctz captopril- olmesartan-amlodipine- 1 1 hydrochlorothiazide hctz CORLANOR 3 PA; QL er 1 DEMSER 3 hcl digitek 1 intravenous solution 10 1 mg/ml digox 1 propranolol-hctz 1 digoxin injection 1 quinapril- 1 digoxin oral 1 hydrochlorothiazide hcl 1 ranolazine er 1 dobutamine in d5w 1 -hctz 1 dopamine hcl 1 telmisartan-amlodipine 1 intravenous telmisartan-hctz 1 dopamine in d5w 1 trandolapril-verapamil enalapril- 1 1 hcl er hydrochlorothiazide triamterene-hctz 1 ENTRESTO 2 QL

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29 Drug Name Drug Tier Notes Drug Name Drug Tier Notes valsartan- fenofibric acid oral 1 hydrochlorothiazide capsule delayed 1 VYNDAMAX 4 PA; QL release Diuretics, Carbonic gemfibrozil oral 1 Anhydrase Inhibitors Dyslipidemics, HMG er 1 CoA Reductase Inhibitors acetazolamide oral 1 atorvastatin calcium acetazolamide sodium 1 oral tablet 10 mg, 20 1 PV* oral 1 mg Diuretics, Loop atorvastatin calcium 1 oral tablet 40 mg, 80 1 mg ethacrynate sodium 1 LIVALO 3 ST ethacrynic acid 1 lovastatin oral 1 PV injection 1 pravastatin sodium 1 furosemide oral 1 rosuvastatin calcium 1 torsemide 1 simvastatin oral tablet Diuretics, Potassium- 10 mg, 20 mg, 40 mg, 5 1 PV* sparing mg amiloride hcl oral 1 simvastatin oral tablet 1 eplerenone 1 80 mg spironolactone oral 1 Dyslipidemics, Other triamterene oral 1 cholestyramine light 1 Diuretics, Thiazide cholestyramine oral 1 chlorthalidone 1 colesevelam hcl 1 hydrochlorothiazide colestipol hcl 1 1 oral ezetimibe 1 indapamide 1 ezetimibe-simvastatin 1 metolazone 1 NEXLETOL 2 PA; QL Dyslipidemics, Fibric NEXLIZET 2 PA; QL Acid Derivatives er 1 fenofibrate micronized 1 (antihyperlipidemic) fenofibrate oral capsule 1 omega-3-acid ethyl 1 PA fenofibrate oral tablet esters 145 mg, 160 mg, 48 1 PRALUENT 2 PA; QL mg, 54 mg prevalite 1 REPATHA 2 PA; QL

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30 Drug Name Drug Tier Notes Drug Name Drug Tier Notes REPATHA dextroamphetamine 1 PA; QL PUSHTRONEX 2 PA; QL sulfate SYSTEM dextroamphetamine 1 PA; QL REPATHA sulfate er 2 PA; QL SURECLICK VYVANSE 2 PA; QL Vasodilators, Direct- Attention Deficit acting Arterial Hyperactivity hydralazine hcl Disorder Agents, 1 injection Non- hydralazine hcl oral 1 hcl 1 QL minoxidil oral 1 clonidine hcl er 1 Vasodilators, Direct- DAYTRANA 3 ST; PA; QL acting hcl 1 PA; QL Arterial/Venous dexmethylphenidate hcl 1 PA; QL DILATRATE-SR 3 er isosorbide dinitrate oral guanfacine hcl er 1 tablet 10 mg, 20 mg, 30 1 mg, 5 mg hcl er 1 PA; QL methylphenidate hcl er isosorbide mononitrate 1 1 PA; QL (cd) isosorbide mononitrate 1 methylphenidate hcl er er 1 PA; QL (la) NITRO-BID 3 methylphenidate hcl er 1 PA; QL nitroglycerin 1 (xr) nitroglycerin in d5w 1 methylphenidate hcl 1 PA; QL NITROMIST 3 oral nitroprusside sodium 1 QUILLIVANT XR 3 ST; PA; QL RECTIV 3 relexxii 1 PA; QL 1 Central Nervous Central Nervous System, Other System Agents 1 Attention Deficit GRALISE ORAL 3 ST; QL Hyperactivity TABLET Disorder Agents, riluzole 1 PA; QL Amphetamines tetrabenazine 4 PA sulfate 1 PA; QL Fibromyalgia Agents amphetamine- 1 PA; QL dextroamphetamine pregabalin oral 1 QL amphetamine- SAVELLA 3 ST; QL 1 PA; QL dextroamphetamine er

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31 Drug Name Drug Tier Notes Drug Name Drug Tier Notes SAVELLA TITRATION FLUORIDEX 3 ST; QL 3 PACK SENSITIVITY RELIEF Multiple Sclerosis oralone 1 Agents periogard 1 AVONEX PEN 4 PA; QL hcl oral 1 AVONEX PREFILLED 4 PA; QL prevident mouth/throat 1 BAFIERTAM 4 PA; QL 5000 1 BETASERON 4 PA; QL enamel COPAXONE 4 PA; QL sodium fluoride 5000 1 dalfampridine er 4 PA; QL plus sodium fluoride 5000 dimethyl fumarate oral 4 PA; QL 1 ppm dimethyl fumarate 4 PA; QL sodium fluoride 5000 starter pack 1 sensitive GILENYA 4 PA; QL sodium fluoride dental 1 glatiramer acetate 4 PA; QL 1 glatopa 4 PA; QL mouth/throat MAYZENT 4 PA; QL Dermatological MAYZENT STARTER Agents 4 PA; QL PACK accutane 1 PA TECFIDERA 4 PA; QL acitretin 1 TYSABRI 4 PA; QL adapalene external 1 PA Dental and Oral cream Agents adapalene external gel 1 PA cavarest 1 adapalene-benzoyl 1 cevimeline hcl 1 peroxide external gel chlorhexidine gluconate ammonium lactate 1 1 mouth/throat external CLINPRO 5000 3 amnesteem 1 PA DEBACTEROL 3 azelaic acid external 1 DENTA 5000 PLUS 3 AZELEX 3 DENTAGEL 3 benzoyl peroxide- 1 easygel 1 erythromycin calcipotriene external FLUORIDEX 3 1 cream fluoridex daily renewal 1 calcipotriene external 1 FLUORIDEX ointment ENHANCED 3 WHITENING

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32 Drug Name Drug Tier Notes Drug Name Drug Tier Notes calcipotriene external rosadan external gel 1 1 solution SANTYL 3 calcipotriene-betameth selenium sulfide 1 diprop external 1 QL external lotion suspension STELARA 4 PA calcitriol external 1 INTRAVENOUS claravis 1 PA STELARA 4 PA; QL clindacin etz external SUBCUTANEOUS 1 swab sulfacetamide sodium 1 clindacin-p 1 (acne) clindamycin phosphate- tacrolimus external 1 1 benzoyl peroxide ointment clindamycin phosphate TALTZ 4 PA 1 external tazarotene external 1 clindamycin-tretinoin 1 TAZORAC EXTERNAL 3 coal tar external 1 CREAM 0.05 % CONDYLOX 3 TAZORAC EXTERNAL 3 dapsone external 1 GEL doxepin hcl external 3 TREMFYA 4 PA DUPIXENT 4 PA; QL tretinoin external 1 PA EPIDUO FORTE 3 tretinoin microsphere 1 PA tretinoin microsphere ery 1 1 PA pump erythromycin external 1 zenatane 1 PA imiquimod external 1 cream 5 % Electrolytes/Minerals/ Metals/Vitamins isotretinoin oral 1 PA Electrolyte/Mineral lactic acid e 1 Replacement lactic acid external 1 calcium chloride 1 methoxsalen rapid 1 1 metronidazole external 1 intravenous MIRVASO 2 CARBAGLU 4 myorisan 1 PA chromic chloride 1 neuac external gel 1 intravenous dextrose in lactated pimecrolimus 1 1 ringers podofilox external 1 dextrose intravenous 1 REGRANEX 3 PA dextrose-nacl 1 rosadan external cream 1

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33 Drug Name Drug Tier Notes Drug Name Drug Tier Notes dextrose-sodium na ferric gluc cplx in 1 1 chloride sucrose effer-k oral tablet nafrinse 1 PV 1 effervescent 25 meq nafrinse drops 1 PV ferocon 1 nutrilipid 1 ferotrinsic 1 phosphorous 1 ferraplus 90 1 phospho-trin 250 1 ferrocite plus 1 neutral fluoritab 1 PV polysaccharide iron 1 foltrin 1 forte potassium acetate hemocyte-f 1 1 intravenous iodine strong oral 1 potassium chloride crys 1 kcl in dextrose-nacl 1 er kcl-lactated ringers-d5w 1 potassium chloride er 1 klor-con 1 potassium chloride in 1 klor-con 10 1 dextrose klor-con m10 1 potassium chloride in 1 KLOR-CON M15 3 nacl potassium chloride klor-con m20 1 1 intravenous klor-con/ef 1 potassium chloride oral 1 k-prime 1 potassium citrate er 1 k-tan plus 1 potassium lactated ringers 1 1 phosphates(71 meq k) intravenous purevit dualfe plus 1 levocarnitine oral 1 solution ringers 1 levocarnitine oral tablet 1 se-tan plus 1 levocarnitine sf 1 sod citrate- 1 chloride sodium acetate 1 1 injection intravenous in sodium bicarbonate 1 1 d5w intravenous magnesium sulfate (pf) 1 1 injection sodium chloride 1 magnesium sulfate injection 1 intravenous sodium chloride 1 intravenous

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34 Drug Name Drug Tier Notes Drug Name Drug Tier Notes sodium fluoride oral 1 PV cyanocobalamin sodium phosphates 1 injection solution 1000 1 mcg/ml tl-hem 150 1 ergocalciferol oral 1 virt-phos 250 neutral 1 capsule Electrolyte/Mineral/Me fabb 1 tal Modifiers fa-vitamin b-6-vitamin 1 CHEMET 3 b-12 clovique 4 PA folbee 1 deferasirox 1 PA folbee plus 1 deferasirox granules 1 PA folic acid injection 1 deferiprone 1 PA folic acid oral tablet 1 1 sodium polystyrene mg 1 sulfonate folplex 2.2 1 sps 1 1 trientine hcl 4 PA acetate VELTASSA 3 lysiplex plus oral tablet 1 Phosphate Binders multi prenatal 1 PV calcium acetate (phos multi-vit/iron/fluoride 1 1 binder) multi-vitamin/fluoride 1 calcium acetate oral multivitamin/fluoride 1 1 tablet 667 mg oral solution FOSRENOL ORAL 3 multivitamin/fluoride PACKET oral tablet chewable 1 lanthanum carbonate 1 0.25 mg, 0.5 mg, 1 mg PHOSLYRA 3 multi- 1 sevelamer carbonate 1 vitamin/fluoride/iron sevelamer hcl 1 NASCOBAL 3 Vitamins nephronex oral tablet 1 adc/f (0.5mg/ml) 1 nufol 1 airavite 1 nutrifac zx 1 b-6 folic acid 1 ONE VITE WOMENS 3 PV ONE-A-DAY WOMENS biocel 1 3 PV PRENATAL 1 bp vit 3 1 phytonadione injection 1 b-plex 1 phytonadione oral 1 b-plex plus 1 prenatal multi +dha 1 PV cod oil oral oil 1

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35 Drug Name Drug Tier Notes Drug Name Drug Tier Notes prenatal oral tablet 27- CUVPOSA 3 1 PV 0.8 mg dicyclomine hcl 1 prenatal oral tablet 27-1 intramuscular 1 mg dicyclomine hcl oral 1 prenatal plus iron 1 ED-SPAZ 1 prenatal vitamin plus glycopyrrolate injection 1 1 low iron solution preplus 1 glycopyrrolate oral 1 pyridoxine hcl injection 1 tablet 1 mg, 2 mg hcl injection 1 glycopyrrolate pf 1 tri-vite/fluoride 1 sulfate 1 v-c forte 1 oral virt-caps 1 hyoscyamine sulfate sl 1 hyoscyamine sulfate virt-gard 1 1 sublingual vita s forte 1 methscopolamine 3 vitacel 1 bromide oral vita-min 1 oscimin 1 vitamin d Gastrointestinal (ergocalciferol) oral 1 Agents, Other capsule 1.25 mg (50000 ut) alvimopan 1 amoxicill-clarithro- vitamin k1 injection 1 1 lansopraz vitamins acd-fluoride 1 cromolyn sodium oral 1 vp-pnv-dha 1 - 1 vp-vite rx 1 GATTEX 4 PA westab mini 1 hcl oral 1 westab one 1 capsule Gastrointestinal MOTOFEN 3 Agents OMECLAMOX-PAK 2 Antispasmodics, Gastrointestinal PYLERA 2 sodium bicarbonate atropine sulfate 1 injection solution 8 1 oral powder mg/20ml SYMPROIC 2 ST; QL atropine sulfate ursodiol oral 1 injection solution 1 Histamine2 (H2) prefilled syringe 0.5 Receptor Antagonists mg/5ml hcl 1

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36 Drug Name Drug Tier Notes Drug Name Drug Tier Notes cimetidine oral 1 mm clearlax 1 PV; QL famotidine intravenous 1 peg 3350-kcl-na bicarb- 1 PV; QL famotidine oral nacl suspension 1 peg-3350/electrolytes 1 PV; QL reconstituted peg- famotidine oral tablet 3350/electrolytes/ascor 1 1 20 mg, 40 mg bat famotidine premixed 1 peg-kcl-nacl-nasulf-na 1 nizatidine 1 asc-c Irritable Bowel qc 1 PV; QL Syndrome Agents SUPREP BOWEL 3 hcl 1 PA PREP KIT LINZESS 2 ST; QL Protectants misoprostol oral 1 ec 1 PV; QL sucralfate oral 1 cascara sagrada oral Proton Pump 1 fluid extract Inhibitors citroma 1 PV; QL DEXILANT 2 QL clearlax 1 PV; QL esomeprazole sodium 1 CLENPIQ 3 lansoprazole oral capsule delayed 1 QL constulose 1 release enulose 1 lansoprazole oral tablet gavilax oral powder 1 PV; QL delayed release 1 QL gavilyte-c 1 PV; QL dispersible 15 mg gavilyte-g 1 PV; QL omeprazole oral capsule delayed 1 QL gavilyte-h 1 release gavilyte-n with flavor pantoprazole sodium 1 PV; QL 1 QL pack intravenous generlac 1 pantoprazole sodium 1 QL gentle oral 1 PV; QL oral glycolax 1 PV; QL rabeprazole sodium oral tablet delayed 1 QL 1 encephalopathy release lactulose oral solution 1 Genetic or Enzyme Disorder: magnesium citrate oral 1 PV; QL Replacement, solution Modifiers, Treatment heavy oral 1 ALDURAZYME 4 PA

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37 Drug Name Drug Tier Notes Drug Name Drug Tier Notes CERDELGA 4 PA ZENPEP ORAL CHOLBAM 4 PA CAPSULE DELAYED RELEASE PARTICLES CREON 2 10000-32000 UNIT, CYSTAGON 4 15000-47000 UNIT, 2 ELAPRASE 4 PA 20000-63000 UNIT, 3000-14000 UNIT, EVRYSDI 4 PA; QL 40000-126000 UNIT, FABRAZYME 4 PA 5000-24000 UNIT KANUMA 4 PA Genitourinary Agents KUVAN 4 PA Antispasmodics, LUMIZYME 4 PA Urinary MEPSEVII 4 PA 1 hydrobromide er miglustat 4 PA hcl 1 MYALEPT 4 PA GELNIQUE 3 ST NAGLAZYME 4 PA MYRBETRIQ 2 nitisinone 4 PA chloride er 1 ORFADIN ORAL 4 PA CAPSULE 20 MG oxybutynin chloride oral 1 ORFADIN ORAL succinate 1 4 PA SUSPENSION tartrate 1 PROLASTIN-C 4 PA tolterodine tartrate er 1 RAVICTI 4 PA TOVIAZ 3 REVCOVI 4 PA 1 sapropterin trospium chloride er 1 4 PA dihydrochloride urin ds 1 sod benz-sod 1 Benign Prostatic phenylacet Hypertrophy Agents sodium phenylbutyrate 4 hcl er 1 oral dutasteride oral 1 STRENSIQ 4 PA dutasteride- 1 SUCRAID 4 hcl TEGSEDI 4 PA finasteride oral tablet 5 1 VIMIZIM 4 PA mg ZEMAIRA 4 PA 1 tadalafil oral tablet 2.5 1 PA; QL mg, 5 mg tamsulosin hcl 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

38 Drug Name Drug Tier Notes Drug Name Drug Tier Notes hcl 1 Hormonal Agents, Genitourinary Agents, Stimulant/Replaceme Other nt/Modifying (Adrenal) irrigation 1 ala-cort 1 aminoacetic acid 1 1 argyle sterile saline 1 dipropionate chloride external 1 1 oral lotion curity sterile saline 1 beser external lotion 1 ELMIRON 2 betamethasone 1 ENCARE 3 PV; QL dipropionate aug irrigation 1 betamethasone 1 glycine urologic 1 dipropionate external neomycin- betamethasone sod 1 phos & acet injection gu 1 suspension 6 (3-3) penicillamine oral 4 PA mg/ml capsule betamethasone 1 penicillamine oral tablet 4 valerate external phenazo oral tablet 200 clobetasol prop 1 1 mg emollient base phenazopyridine hcl e 1 oral tablet 100 mg, 200 1 clobetasol propionate mg 1 emulsion RENACIDIN 3 clobetasol propionate sodium chloride 1 1 external irrigation pivalate 1 irrigation 1 clodan external solution 3.3 % 1 shampoo sorbitol- 1 DEPO-MEDROL TODAY SPONGE 3 PV; QL INJECTION 3 VCF VAGINAL SUSPENSION 20 CONTRACEPTIVE 3 PV; QL MG/ML VAGINAL FILM external 1 vcf vaginal cream contraceptive vaginal 1 PV; QL desonide external lotion 1 gel desonide external 1 ointment

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

39 Drug Name Drug Tier Notes Drug Name Drug Tier Notes butyrate 1 1 external cream 0.25 % external solution desoximetasone hydrocortisone external 1 1 external gel cream 1 %, 2.5 % desoximetasone hydrocortisone external 1 1 external liquid lotion 2.5 % desoximetasone hydrocortisone external 1 external ointment 0.25 1 ointment 1 %, 2.5 % % hydrocortisone oral 1 1 1 intensol dexamethasone oral 1 acetate injection 1 dexamethasone sod suspension 40 mg/ml, 1 phosphate pf 80 mg/ml dexamethasone methylprednisolone 1 sodium phosphate 1 oral injection methylprednisolone 1 acetate sodium succ 1 oral furoate 1 external 1 body 1 fluocinolone acetonide oral 1 1 external solution fluocinolone acetonide prednisolone sodium 1 1 scalp phosphate oral emulsified 1 intensol 1 base prednisone oral 1 fluocinonide external 1 SOLU-CORTEF propionate 1 INJECTION external SOLUTION 3 3 RECONSTITUTED halobetasol propionate 1000 MG 1 external cream TEXACORT 3 halobetasol propionate tovet external foam 1 1 external ointment triamcinolone acetonide 1 external cream 1 external cream triamcinolone acetonide 1 hydrocortisone butyrate external lotion 1 external ointment triamcinolone acetonide 1 external ointment

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

40 Drug Name Drug Tier Notes Drug Name Drug Tier Notes triamcinolone acetonide Hormonal Agents, injection suspension 40 1 Stimulant/Replaceme mg/ml nt/Modifying (Sex triderm 1 Hormones/Modifiers) Hormonal Agents, Androgens Stimulant/Replaceme oral 1 nt/Modifying INTRAROSA 3 (Pituitary) METHITEST 3 PA ACTHAR 4 PA oxandrolone oral 1 PA; QL 1 cypionate chorionic gonadotropin 1 PA 4 PA intramuscular intramuscular testosterone enanthate desmopressin ace 1 PA 1 intramuscular spray refrig testosterone desmopressin acetate 1 transdermal gel 1.62 %, injection 12.5 mg/act (1%), desmopressin acetate 20.25 mg/1.25gm 1 oral (1.62%), 20.25 mg/act 1 PA desmopressin acetate (1.62%), 25 mg/2.5gm 1 spray (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm INCRELEX 4 PA (1%) NORDITROPIN testosterone 4 PA 1 PA FLEXPRO transdermal solution novarel intramuscular Estrogens solution reconstituted 4 PA 10000 unit afirmelle 1 PV NUTROPIN AQ altavera 1 PV 4 PA NUSPIN 10 alyacen 1/35 1 PV NUTROPIN AQ alyacen 7/7/7 1 PV 4 PA NUSPIN 20 amabelz 1 NUTROPIN AQ 4 PA amethia 1 PV; QL NUSPIN 5 amethia lo 1 PV; QL oxytocin injection 1 amethyst 1 PV pregnyl 4 PA apri 1 PV Hormonal Agents, Stimulant/Replaceme aranelle 1 PV nt/Modifying ashlyna 1 PV; QL (Prostaglandins) aubra 1 PV KORLYM 4 PA; QL aubra eq 1 PV 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

41 Drug Name Drug Tier Notes Drug Name Drug Tier Notes aurovela 1.5/30 1 PV drospiren-eth estrad- 1 PV aurovela 1/20 1 PV levomefol drospirenone-ethinyl aurovela 24 fe 1 PV 1 PV aurovela fe 1.5/30 1 PV DUAVEE 2 aurovela fe 1/20 1 PV elinest 1 PV aviane 1 PV eluryng 1 PV ayuna 1 PV emoquette 1 PV azurette 1 PV enpresse-28 1 PV balziva 1 PV enskyce 1 PV bekyree 1 PV estarylla 1 PV BIJUVA 3 estradiol oral 1 blisovi 24 fe 1 PV estradiol transdermal 1 blisovi fe 1.5/30 1 PV estradiol vaginal 1 blisovi fe 1/20 1 PV estradiol valerate 1 briellyn 1 PV intramuscular camrese 1 PV; QL estradiol-norethindrone 1 camrese lo 1 PV; QL acet caziant 1 PV ethynodiol diac-eth 1 PV charlotte 24 fe 1 PV estradiol -ethinyl chateal 1 PV 1 PV estradiol chateal eq 1 PV EVAMIST 3 COMBIPATCH 3 falmina 1 PV cryselle-28 1 PV fayosim 1 PV; QL cyclafem 1/35 1 PV femynor 1 PV cyclafem 7/7/7 1 PV fyavolv 1 cyred 1 PV gemmily 1 PV cyred eq 1 PV hailey 1.5/30 1 PV dasetta 1/35 1 PV hailey 24 fe 1 PV dasetta 7/7/7 1 PV hailey fe 1.5/30 1 PV daysee 1 PV; QL hailey fe 1/20 1 PV delyla 1 PV iclevia 1 PV; QL -ethinyl 1 PV estradiol introvale 1 PV; QL DIVIGEL 3 isibloom 1 PV dotti 1 jaimiess 1 PV; QL

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42 Drug Name Drug Tier Notes Drug Name Drug Tier Notes jasmiel 1 PV low-ogestrel 1 PV jinteli 1 lo-zumandimine 1 PV jolessa 1 PV; QL lutera 1 PV juleber 1 PV lyllana 1 junel 1.5/30 1 PV marlissa 1 PV junel 1/20 1 PV melodetta 24 fe 1 PV junel fe 1.5/30 1 PV MENEST 2 junel fe 1/20 1 PV merzee 1 PV junel fe 24 1 PV mibelas 24 fe 1 PV kalliga 1 PV microgestin 1.5/30 1 PV kariva 1 PV microgestin 1/20 1 PV kelnor 1/35 1 PV microgestin 24 fe 1 PV kelnor 1/50 1 PV microgestin fe 1.5/30 1 PV kurvelo 1 PV microgestin fe 1/20 1 PV larin 1.5/30 1 PV mili 1 PV larin 1/20 1 PV mimvey 1 larin 24 fe 1 PV mono-linyah 1 PV larin fe 1.5/30 1 PV NATAZIA 2 PV larin fe 1/20 1 PV necon 0.5/35 (28) 1 PV larissia 1 PV nikki 1 PV layolis fe 1 PV norethin ace-eth 1 PV leena 1 PV estrad-fe norethindrone acet- lessina 1 PV 1 PV ethinyl est levonest 1 PV norethindrone-eth levonorgest-eth est & 1 1 PV; QL estradiol eth est norethin-eth estradiol-fe 1 PV levonorgest-eth estrad 1 PV; QL norgestimate-eth 91-day 1 PV estradiol levonorgestrel-ethinyl 1 PV norgestimate-ethinyl estrad 1 PV estradiol triphasic levonorg-eth estrad 1 PV triphasic nortrel 0.5/35 (28) 1 PV levora 0.15/30 (28) 1 PV nortrel 1/35 (21) 1 PV lillow 1 PV nortrel 1/35 (28) 1 PV lojaimiess 1 PV; QL nortrel 7/7/7 1 PV loryna 1 PV nylia 7/7/7 1 PV

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43 Drug Name Drug Tier Notes Drug Name Drug Tier Notes nymyo 1 PV tri-sprintec 1 PV ocella 1 PV trivora (28) 1 PV orsythia 1 PV tri-vylibra 1 PV philith 1 PV tri-vylibra lo 1 PV pimtrea 1 PV tyblume 1 PV pirmella 1/35 1 PV tydemy 1 PV pirmella 7/7/7 1 PV velivet 1 PV portia-28 1 PV vestura 1 PV PREMARIN ORAL 2 vienva 1 PV PREMPHASE 2 viorele 1 PV PREMPRO 2 volnea 1 PV previfem 1 PV vyfemla 1 PV reclipsen 1 PV vylibra 1 PV rivelsa 1 PV; QL wera 1 PV setlakin 1 PV; QL wymzya fe 1 PV simliya 1 PV xulane 1 PV simpesse 1 PV; QL yuvafem 1 sprintec 28 1 PV zafemy 1 PV sronyx 1 PV zarah 1 PV syeda 1 PV zovia 1/35 (28) 1 PV tarina 24 fe 1 PV zovia 1/35e (28) 1 PV tarina fe 1/20 1 PV zumandimine 1 PV tarina fe 1/20 eq 1 PV Progestins tilia fe 1 PV camila 1 PV tri femynor 1 PV deblitane 1 PV tri-estarylla 1 PV DEPO-SUBQ 3 QL tri-legest fe 1 PV PROVERA 104 tri-linyah 1 PV ELLA 3 PV tri-lo-estarylla 1 PV errin 1 PV tri-lo-marzia 1 PV heather 1 PV tri-lo-mili 1 PV hydroxyprogesterone caproate intramuscular 4 PA tri-lo-sprintec 1 PV oil tri-mili 1 PV incassia 1 PV tri-nymyo 1 PV jencycla 1 PV tri-previfem 1 PV KYLEENA 3 PV

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44 Drug Name Drug Tier Notes Drug Name Drug Tier Notes levonorgestrel 1 PV levothyroxine sodium 1 LILETTA (52 MG) 3 PV intravenous levothyroxine sodium lyleq 1 PV 1 oral tablet lyza 1 PV levoxyl 1 MAKENA 4 PA liothyronine sodium SUBCUTANEOUS 1 intravenous medroxyprogesterone 1 PV; QL acetate intramuscular liothyronine sodium oral 1 medroxyprogesterone np thyroid 1 1 acetate oral unithroid 1 oral 1 Hormonal Agents, MIRENA (52 MG) 3 PV Suppressant (Adrenal) NEXPLANON 3 PV LYSODREN 2 nora-be 1 PV Hormonal Agents, norethindrone acetate 1 Suppressant oral (Pituitary) norethindrone oral 1 PV leuprolide acetate 4 PA norlyda 1 PV injection norlyroc 1 PV LUPRON DEPOT (1- 4 PA preventeza 1 PV MONTH) LUPRON DEPOT (3- 1 4 PA intramuscular MONTH) progesterone LUPRON DEPOT (4- 1 MONTH) micronized oral 4 PA INTRAMUSCULAR KIT sharobel 1 PV 30MG SKYLA 3 PV LUPRON DEPOT (6- tulana 1 PV MONTH) 4 PA Selective Estrogen INTRAMUSCULAR KIT Receptor Modifying 45MG Agents LUPRON DEPOT-PED 4 PA OSPHENA 3 (1-MONTH) LUPRON DEPOT-PED raloxifene hcl 1 PV* 4 PA (3-MONTH) Hormonal Agents, Stimulant/Replaceme acetate 4 PA nt/Modifying (Thyroid) SIGNIFOR 4 PA; QL euthyrox 1 SOMATULINE DEPOT 4 PA levo-t 1 SOMAVERT 4 PA

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45 Drug Name Drug Tier Notes Drug Name Drug Tier Notes SYNAREL 2 HUMIRA PEN 4 PA Hormonal Agents, HUMIRA PEN- 4 PA Suppressant CD/UC/HS STARTER (Thyroid) HUMIRA PEN- Antithyroid Agents PEDIATRIC UC 4 PA methimazole oral 1 START propylthiouracil oral 1 HUMIRA PEN- PS/UV/ADOL HS 4 PA Immunological START Agents HUMIRA PEN- Angioedema Agents PSOR/UVEIT 4 PA BERINERT 4 PA; QL STARTER CINRYZE 4 PA INFLECTRA 4 PA icatibant acetate 4 PA KINERET 4 PA Immune oral 1 Suppressants methotrexate sodium 1 AVSOLA 4 PA methotrexate sodium 1 AZASAN 3 (pf) oral 1 mycophenolate mofetil 1 azathioprine sodium 1 hcl mycophenolate mofetil CIMZIA 4 PA 1 oral CIMZIA PREFILLED 4 PA KIT mycophenolate sodium 1 CIMZIA STARTER KIT 4 PA ORENCIA 4 PA cyclosporine ORENCIA CLICKJECT 4 PA 1 intravenous PROGRAF 3 cyclosporine modified 1 INTRAVENOUS cyclosporine oral 1 RENFLEXIS 4 PA SANDIMMUNE ORAL ENBREL 4 PA 2 SOLUTION ENBREL MINI 4 PA SIMPONI 4 PA ENBREL SURECLICK 4 PA SIMPONI ARIA 4 PA everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 1 sirolimus oral 1 mg SKYRIZI (150 MG 4 PA gengraf 1 DOSE) HUMIRA 4 PA tacrolimus oral 1 HUMIRA PEDIATRIC temsirolimus 4 4 PA CROHNS START TREXALL 3

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46 Drug Name Drug Tier Notes Drug Name Drug Tier Notes XELJANZ 4 PA ACTIMMUNE 4 PA XELJANZ XR 4 PA ALFERON N 4 ZORTRESS ORAL GAMIFANT 4 PA 3 TABLET 1 MG ILARIS 4 PA; QL Immunoglobulins leflunomide oral 1 BIVIGAM 4 PA OTEZLA 4 PA CARIMUNE NF 4 PA RINVOQ 4 PA CUVITRU 4 PA ULTOMIRIS 4 PA CYTOGAM 4 PA XOLAIR 4 PA FLEBOGAMMA DIF 4 PA Vaccines GAMASTAN 4 PA ACTHIB 2 PV GAMMAGARD 4 PA ADACEL 2 PV GAMMAGARD S/D AFLURIA 4 PA 2 PV LESS IGA QUADRIVALENT GAMMAKED 4 PA BEXSERO 2 PV GAMMAPLEX 4 PA BOOSTRIX 2 PV GAMUNEX-C 4 PA DAPTACEL 2 PV HEPAGAM B 4 DIPHTHERIA- HIZENTRA 4 PA TETANUS TOXOIDS 2 PV HYPERHEP B 4 DT HYPERRHO S/D 4 ENGERIX-B 2 PV HYQVIA 4 PA FLUAD 2 PV MICRHOGAM ULTRA- FLUAD 4 2 PV FILTERED PLUS QUADRIVALENT FLUARIX NABI-HB 4 2 PV QUADRIVALENT OCTAGAM 4 PA FLUBLOK 2 PV PRIVIGEN 4 PA QUADRIVALENT RHOGAM ULTRA- FLUCELVAX 4 2 PV FILTERED PLUS QUADRIVALENT RHOPHYLAC 4 FLULAVAL 2 PV SYNAGIS 4 PA QUADRIVALENT THYMOGLOBULIN 3 FLUMIST 2 PV WINRHO SDF 4 QUADRIVALENT Immunomodulators FLUZONE HIGH- DOSE 2 PV ACTEMRA 4 PA QUADRIVALENT ACTEMRA ACTPEN 4 PA

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47 Drug Name Drug Tier Notes Drug Name Drug Tier Notes FLUZONE Inflammatory Bowel 2 PV QUADRIVALENT Disease Agents GARDASIL 9 2 PV Aminosalicylates HAVRIX 2 PV balsalazide disodium 1 HEPLISAV-B 2 PV DIPENTUM 3 HIBERIX 2 PV mesalamine er oral 1 INFANRIX 2 PV capsule 0.375 gm IPOL 2 PV mesalamine oral capsule delayed 1 KINRIX 2 PV release 400 mg MENACTRA 2 PV mesalamine oral tablet 1 MENQUADFI 2 PV delayed release 1.2 gm MENVEO 2 PV mesalamine rectal 1 M-M-R II 2 PV mesalamine-cleanser 1 PEDIARIX 2 PV PENTASA 3 PEDVAX HIB 2 PV PENTACEL 2 PV er 1 PNEUMOVAX 23 2 PV budesonide oral 1 PREVNAR 13 2 PV CORTIFOAM 3 PROQUAD 2 PV hydrocortisone 1 QUADRACEL 2 PV (perianal) RECOMBIVAX HB 2 PV hydrocortisone ace- pramoxine external 1 ROTARIX 2 PV cream 1-1 % ROTATEQ 2 PV hydrocortisone rectal 1 SHINGRIX 2 PV procto-med hc 1 TDVAX 2 PV procto-pak 1 TENIVAC 2 PV proctozone-hc 1 TETANUS- Sulfonamides DIPHTHERIA 2 PV TOXOIDS TD sulfasalazine oral 1 TRUMENBA 2 PV Metabolic Bone Disease Agents TWINRIX 2 PV alendronate sodium 1 VAQTA 2 PV oral solution VARIVAX 2 PV alendronate sodium 1 VAXELIS 2 PV oral tablet 10 mg, 5 mg

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48 Drug Name Drug Tier Notes Drug Name Drug Tier Notes alendronate sodium BD AUTOSHIELD DUO 2 oral tablet 35 mg, 70 1 QL PEN NEEDLES mg BD ULTRA-FINE 2 calcitonin (salmon) 1 QL INSULIN SYRINGES calcitriol intravenous 1 BD ULTRA-FINE PEN 2 calcitriol oral 1 NEEDLES BD VEO INSULIN SYR cinacalcet hcl 1 PA 2 U/F 1/2UNIT doxercalciferol 1 benzalkonium chloride intravenous 1 external solution FORTEO 4 PA PA; Non- BOTOX 4 ibandronate sodium 1 QL Cosmetic MIACALCIN BREATHE EASE 3 2 INJECTION LARGE pamidronate disodium 4 BREATHE EASE 2 paricalcitol 1 MEDIUM PROLIA 4 PA; QL BREATHE EASE 2 RAYALDEE 3 SMALL risedronate sodium oral CAYA 3 PV; QL 1 QL tablet 150 mg, 35 mg CLEVER CHOICE 2 risedronate sodium oral HOLDING CHAMBER 1 tablet 30 mg, 5 mg COMFORT TOUCH 3 risedronate sodium oral ALCOHOL PREP 1 QL tablet delayed release COMPACT SPACE 2 TERIPARATIDE CHAMBER/LG MASK 4 PA (RECOMBINANT) COMPACT SPACE XGEVA 4 PA CHAMBER/MED 2 MASK zoledronic acid 4 COMPACT SPACE 2 Miscellaneous CHAMBER/SM MASK Therapeutic Agents deferoxamine mesylate 1 albumin human 1 hcl in albumin-zlb 1 nacl intravenous 1 alburx 1 solution ALCOHOL PREP dexmedetomidine hcl 3 PADS PAD intravenous solution 1 ALCOHOL PREP 200 mcg/2ml 3 PADS PAD 70 % DROPLET MICRON 2 argyle sterile 1 EASIVENT 2 bal in oil 1 mesylates oral 3

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49 Drug Name Drug Tier Notes Drug Name Drug Tier Notes FC FEMALE CONDOM 3 PV; QL kedbumin 1 FC2 FEMALE lactated ringers 3 PV; QL 1 CONDOM irrigation FEMCAP 3 PV; QL MAXICOMFORT SYR 2 FLEXICHAMBER 27G X 1/2" 2 ADULT MASK/SMALL methergine 1 QL FLEXICHAMBER methylergonovine 2 1 QL CHILD MASK/LARGE maleate oral FLEXICHAMBER MICROCHAMBER 2 2 CHILD MASK/SMALL monoject flush syringe 1 intravenous 1 monoject sodium 1 1 chloride flush heparin lock flush 1 n-acetyl-l- oral 1 heparin sodium lock normal saline flush 1 1 flush NOVOFINE hetastarch-nacl 1 AUTOCOVER PEN 2 INSPIREASE NEEDLE 2 RESERVOIR BAGS NOVOFINE PEN 2 INSULIN PEN NEEDLE 2 NEEDLES NOVOFINE PLUS PEN 2 INSULIN SYRINGES NEEDLE 28G X 1/2" 0.5 ML, NOVOTWIST PEN 2 28G X 1/2" 1 ML, 29G NEEDLE X 1/2" 0.3 ML, 29G X NOZIN NASAL 3 1/2" 0.5 ML, 29G X 1/2" SANITIZER POPSWAB 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, PANDA MASK LARGE 2 30G X 1/2" 1 ML, 30G PANDA MASK 2 X 5/16" 0.3 ML, 30G X MEDIUM 5/16" 0.5 ML, 30G X 2 PANDA MASK SMALL 2 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X PARAGARD 15/64" 0.5 ML, 31G X INTRAUTERINE 3 PV 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X PEDIATRIC PANDA 2 5/16" 0.5 ML, 31G X MASK 5/16" 1 ML, 32G X POCKET SPACER 2 5/16" 0.5 ML, 32G X PRO COMFORT 5/16" 1 ML 2 SPACER ADULT J-TIP KIT W/VIAL 3 PRO COMFORT ADAPTERS 2 SPACER CHILD

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50 Drug Name Drug Tier Notes Drug Name Drug Tier Notes PRO COMFORT WIDE-SEAL 2 3 PV; QL SPACER INFANT DIAPHRAGM 70 PROCARE WIDE-SEAL 3 PV; QL SPACER/ADULT 2 DIAPHRAGM 75 MASK WIDE-SEAL 3 PV; QL PROCARE DIAPHRAGM 80 2 SPACER/CHILD MASK WIDE-SEAL 3 PV; QL ringers irrigation 1 DIAPHRAGM 85 saline flush 1 WIDE-SEAL 3 PV; QL saline flush zr 1 DIAPHRAGM 90 WIDE-SEAL sodium chloride flush 1 3 PV; QL DIAPHRAGM 95 sodium 1 intravenous XIAFLEX 4 PA sodium ZOKINVY 4 PA; QL 1 intravenous Ophthalmic Agents sterile water for Aminoglycosides 1 irrigation gentak 1 swabflush saline flush 1 gentamicin sulfate 1 THYROGEN 4 PA ophthalmic TRUE COMFORT PRO neomycin-polymyxin- 3 1 ALCOHOL PREP TRUE COMFORT PRO TOBRADEX INSULIN SYR 32G X 2 OPHTHALMIC 3 5/16" 0.5 ML OINTMENT TRUE COMFORT PRO TOBRADEX ST 3 PEN NEEDLES 31G X tobramycin ophthalmic 1 8 MM , 32G X 5 MM , 2 tobramycin- 32G X 6 MM , 33G X 4 1 MM , 33G X 5 MM , dexamethasone 33G X 6 MM TOBREX ULTIGUARD OPHTHALMIC 3 SAFEPACK 2 OINTMENT SYR/NEEDLE Antibacterials, Other VISTOGARD 3 ak-poly-bac 1 water for irrigation, bacitracin ophthalmic 1 1 sterile bacitracin-polymyxin b 1 WIDE-SEAL ophthalmic 3 PV; QL DIAPHRAGM 60 bacitra-neomycin- 1 WIDE-SEAL polymyxin-hc 3 PV; QL DIAPHRAGM 65

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51 Drug Name Drug Tier Notes Drug Name Drug Tier Notes neomycin-bacitracin zn- RESTASIS 1 2 PA polymyx MULTIDOSE neomycin-polymyxin- sulfacetamide- dexameth ophthalmic 1 prednisolone 1 ointment ophthalmic solution neomycin-polymyxin- XIIDRA 2 PA dexameth ophthalmic 1 Ophthalmic Anti- suspension 3.5-10000- allergy Agents 0.1 ALOCRIL 3 neomycin-polymyxin-hc 1 ophthalmic ALOMIDE 3 neo-polycin 1 altafrin 1 azelastine hcl neo-polycin hc 1 1 ophthalmic polycin 1 BEPREVE 3 ST polymyxin b- 1 cromolyn sodium trimethoprim 1 ophthalmic Anti-cytomegalovirus (CMV) Agents epinastine hcl 1 ZIRGAN 3 LASTACAFT 3 ST hcl Antifungals 1 ophthalmic NATACYN 2 phenylephrine hcl 1 Antiherpetic Agents ophthalmic trifluridine 1 ZERVIATE 3 ST Macrolides Ophthalmic AZASITE 3 Antiglaucoma Agents erythromycin ALPHAGAN P 1 ophthalmic OPHTHALMIC 2 Ophthalmic Agents, SOLUTION 0.1 % Other hcl 1 atropine sulfate AZOPT 2 1 ophthalmic ointment betaxolol hcl 1 atropine sulfate ophthalmic 1 ophthalmic solution 1 % BETIMOL 3 hcl tartrate 1 1 ophthalmic ophthalmic CYSTARAN 4 PA; QL 1 homatropaire 1 hcl 1 RESTASIS 2 PA COMBIGAN 2

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52 Drug Name Drug Tier Notes Drug Name Drug Tier Notes hcl 1 1 ophthalmic ophthalmic dorzolamide hcl-timolol prednisolone sodium 1 1 mal phosphate ophthalmic dorzolamide hcl-timolol PROLENSA 2 QL 1 mal pf Ophthalmic IOPIDINE 3 and hcl 1 Prostamide Analogs PHOSPHOLINE ophthalmic 1 QL 2 ophthalmic 1 pilocarpine hcl LUMIGAN 2 QL 1 ophthalmic (bak free) 1 QL RHOPRESSA 2 QL ZIOPTAN 3 QL ROCKLATAN 2 QL Quinolones SIMBRINZA 2 BESIVANCE 3 timolol maleate ciprofloxacin hcl 1 1 ophthalmic ophthalmic timolol maleate pf 1 gatifloxacin ophthalmic 1 Ophthalmic Anti- levofloxacin ophthalmic 1 inflammatories moxifloxacin hcl (2x bromfenac sodium 1 1 QL day) (once-daily) moxifloxacin hcl 1 dexamethasone ophthalmic solution sodium phosphate 1 ophthalmic ofloxacin ophthalmic 1 diclofenac sodium Sulfonamides 1 ophthalmic sulfacetamide sodium 1 DUREZOL 3 ophthalmic FLAREX 3 Otic Agents 1 acetic acid otic 1 flurbiprofen sodium 1 CIPRO HC 3 FML 2 CIPRODEX 2 ILEVRO 3 QL ciprofloxacin hcl otic 1 ST ketorolac tromethamine ciprofloxacin- 1 1 ophthalmic dexamethasone etabonate CORTISPORIN-TC 3 1 ophthalmic suspension flac 1

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53 Drug Name Drug Tier Notes Drug Name Drug Tier Notes fluocinolone acetonide Anti-inflammatories, 1 otic Inhaled hydrocortisone-acetic 1 acid ADVAIR HFA 2 QL neomycin-polymyxin-hc ARNUITY ELLIPTA 2 QL 1 otic BREO ELLIPTA 2 QL ofloxacin otic 1 budesonide inhalation 1 QL Respiratory FLOVENT DISKUS 2 QL Tract/Pulmonary Agents FLOVENT HFA 2 QL nasal 1 QL azelastine hcl nasal 1 QL 1 nasal maleate 1 oral solution fluticasone- inhalation aerosol carbinoxamine maleate 1 powder breath oral tablet 4 mg activated 100-50 1 QL cetirizine hcl oral mcg/dose, 250-50 1 solution mcg/dose, 500-50 fumarate mcg/dose 1 oral tablet 2.68 mg FLUTICASONE- hcl oral 1 SALMETEROL INHALATION desloratadine 1 AEROSOL POWDER 1 QL BREATH ACTIVATED 3 maleate oral 113-14 MCG/ACT, 232- diphen oral elixir 1 14 MCG/ACT, 55-14 MCG/ACT hcl 1 mometasone furoate injection 1 QL nasal diphenhydramine hcl 1 PULMICORT oral elixir 2 QL FLEXHALER levocetirizine 1 dihydrochloride oral SYMBICORT 2 QL olopatadine hcl nasal 1 QL wixela inhub 1 QL hcl Antileukotrienes 1 injection montelukast sodium 1 promethazine hcl oral 1 oral promethazine hcl rectal 1 zafirlukast 1 promethegan 1 zileuton er 3 ST ryvent 1

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

54 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Bronchodilators, PROAIR RESPICLICK 2 QL SEREVENT DISKUS 2 QL ATROVENT HFA 3 QL VENTOLIN HFA 2 QL INCRUSE ELLIPTA 2 QL Cystic Fibrosis Agents 1 QL inhalation BETHKIS 4 ipratropium bromide 1 KALYDECO 4 PA nasal ORKAMBI 4 PA; QL SPIRIVA 2 QL HANDIHALER PULMOZYME 4 PA SPIRIVA RESPIMAT 2 QL tobramycin inhalation 4 STIOLTO RESPIMAT 2 QL Mast Cell Stabilizers cromolyn sodium TRELEGY ELLIPTA 1 INHALATION inhalation AEROSOL POWDER 2 QL Phosphodiesterase BREATH ACTIVATED Inhibitors, Airways 100-62.5-25 MCG/INH Disease Bronchodilators, 1 Sympathomimetic intravenous albuterol sulfate hfa 1 QL DALIRESP ORAL 3 PA albuterol sulfate TABLET 500 MCG 1 QL inhalation ELIXOPHYLLIN 2 albuterol sulfate oral THEO-24 3 3 syrup 1 AUVI-Q INJECTION theophylline er 1 SOLUTION AUTO- 3 QL INJECTOR 0.1 theophylline in d5w 1 MG/0.1ML Pulmonary BROVANA 3 QL Antihypertensives epinephrine ADEMPAS 4 PA; QL 1 (anaphylaxis) alyq 4 PA; QL epinephrine injection ambrisentan 4 PA; QL 1 solution auto-injector bosentan 4 PA; QL isoproterenol hcl 1 epoprostenol sodium 4 PA injection OPSUMIT 4 PA; QL levalbuterol hcl 1 QL inhalation ORENITRAM 4 PA sildenafil citrate PERFOROMIST 3 QL 4 PA intravenous PROAIR HFA 2 QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

55 Drug Name Drug Tier Notes Drug Name Drug Tier Notes sildenafil citrate oral TRELEGY ELLIPTA suspension 4 PA; QL INHALATION reconstituted AEROSOL POWDER 2 QL sildenafil citrate oral BREATH ACTIVATED 4 PA; QL tablet 20 mg 200-62.5-25 MCG/INH tadalafil (pah) 4 PA; QL TUZISTRA XR 3 PA; QL TRACLEER 32 MG 4 PA; QL Skeletal Muscle Relaxants 4 PA intrathecal 1 TYVASO 4 PA; QL baclofen oral 1 TYVASO REFILL 4 PA; QL oral 1 TYVASO STARTER 4 PA; QL chlorzoxazone oral 1 UPTRAVI 4 PA; QL tablet 500 mg VELETRI 4 PA hcl 1 VENTAVIS 4 PA; QL oral Pulmonary Fibrosis dantrolene sodium 1 Agents intravenous OFEV 4 PA metaxalone 1 Respiratory Tract methocarbamol 1 Agents, Other injection methocarbamol oral 1 1 inhalation citrate er 1 acetylcysteine orphenadrine citrate 1 1 intravenous injection ANORO ELLIPTA 2 QL revonto 1 azelastine-fluticasone 1 QL hcl oral 1 benzonatate 1 Sleep Disorder COMBIVENT Agents 2 QL RESPIMAT GABA Receptor hydrocodone- Modulators 1 PA; QL 1 QL hydromet 1 PA; QL 1 QL ipratropium-albuterol 1 QL 1 QL NUCALA 4 PA; QL tartrate er 1 QL sodium chloride 1 zolpidem tartrate oral 1 QL inhalation Sleep Disorders, Other 1 PA; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

56 Drug Name Drug Tier Notes BELSOMRA 3 ST; QL doxepin hcl oral tablet 1 QL HETLIOZ 4 PA; QL 1 PA; QL ramelteon 1 QL SUNOSI 2 PA; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

57 Index of Drugs abacavir sulfate...... 22 AKYNZEO...... 14 amlodipine besylate...... 28 abacavir sulfate-lamivudine...... 22 ala-cort...... 39 amlodipine besylate-benazepril abacavir-lamivudine- albendazole...... 19 hcl...... 29 zidovudine...... 22 albumin human...... 49 amlodipine besylate-valsartan.. 29 ABELCET...... 14 albumin-zlb...... 49 amlodipine-atorvastatin...... 29 ABILIFY MAINTENA...... 21 alburx...... 49 amlodipine-olmesartan...... 29 abiraterone acetate...... 16 albuterol sulfate...... 55 amlodipine-valsartan-hctz...... 29 ABRAXANE...... 17 albuterol sulfate hfa...... 55 ammonium lactate...... 32 acamprosate calcium...... 8 alclometasone dipropionate...... 39 amnesteem...... 32 acarbose...... 24 ALCOHOL PREP PADS...... 49 amoxapine...... 13 ACCU-CHEK FASTCLIX ALDURAZYME...... 37 amoxicill-clarithro-lansopraz..... 36 LANCET KIT...... 24 alendronate sodium...... 48, 49 amoxicillin...... 10 ACCU-CHEK SOFTCLIX ALFERON N...... 47 amoxicillin-potassium LANCET DEVICE KIT...... 24 alfuzosin hcl er...... 38 clavulanate...... 10 accutane...... 32 ALIMTA...... 16 amoxicillin-potassium acebutolol hcl...... 28 ALINIA...... 19 clavulanate er...... 10 acetaminophen...... 5 aliskiren fumarate...... 29 amphetamine sulfate...... 31 acetaminophen-codeine...... 6 allopurinol...... 15 amphetamine- acetaminophen-codeine #2...... 6 allopurinol sodium...... 15 dextroamphetamine...... 31 acetaminophen-codeine #3...... 6 almotriptan malate...... 15 amphetamine- acetaminophen-codeine #4...... 6 ALOCRIL...... 52 dextroamphetamine er...... 31 acetazolamide...... 30 ALOMIDE...... 52 ampicillin...... 10 acetazolamide er...... 30 alosetron hcl...... 37 ampicillin sodium...... 10 acetazolamide sodium...... 30 ALPHAGAN P...... 52 ampicillin-sulbactam sodium..... 10 acetic acid...... 39, 53 ALPHANATE...... 26 anagrelide hcl...... 26 acetylcysteine...... 56 alprazolam...... 23 anastrozole...... 18 acitretin...... 32 alprazolam er...... 23 ANORO ELLIPTA...... 56 ACTEMRA...... 47 alprazolam intensol...... 23 ANZEMET...... 14 ACTEMRA ACTPEN...... 47 alprazolam xr...... 23 apap-caff-dihydrocodeine...... 6 ACTHAR...... 41 alprostadil...... 29 APLENZIN...... 12 ACTHIB...... 47 ALTABAX...... 8 APOKYN...... 20 ACTIMMUNE...... 47 altafrin...... 52 apraclonidine hcl...... 52 acyclovir...... 22 altavera...... 41 aprepitant...... 14 acyclovir sodium...... 22 alvimopan...... 36 apri...... 41 ADACEL...... 47 alyacen 1/35...... 41 APTIVUS...... 23 ADAKVEO...... 26 alyacen 7/7/7...... 41 aranelle...... 41 adapalene...... 32 alyq...... 55 ARANESP (ALBUMIN FREE)...26 adapalene-benzoyl peroxide.....32 amabelz...... 41 argatroban...... 26 adc/f (0.5mg/ml)...... 35 amantadine hcl...... 20 argyle sterile saline...... 39 ADCETRIS...... 19 AMBISOME...... 14 argyle sterile water...... 49 adefovir dipivoxil...... 21 ambrisentan...... 55 aripiprazole...... 21 ADEMPAS...... 55 amcinonide...... 39 armodafinil...... 56 adenosine...... 27 amethia...... 41 ARNUITY ELLIPTA...... 54 adriamycin...... 17 amethia lo...... 41 ARRANON...... 17 adult aspirin regimen...... 5 amethyst...... 41 arsenic trioxide...... 17 ADVAIR HFA...... 54 amikacin sulfate...... 8 ARZERRA...... 19 ADVATE...... 26 amiloride hcl...... 30 ascomp-codeine...... 6 AFINITOR DISPERZ...... 18 amiloride-hydrochlorothiazide... 29 asenapine maleate...... 21 afirmelle...... 41 aminoacetic acid...... 39 ashlyna...... 41 AFLURIA QUADRIVALENT...... 47 aminocaproic acid...... 26 aspirin...... 5 AIMOVIG...... 15 aminophylline...... 55 aspirin adult low strength...... 5 airavite...... 35 amiodarone hcl...... 27 aspirin childrens...... 5 ak-poly-bac...... 51 amitriptyline hcl...... 13 aspirin ec...... 5 58 aspirin ec low dose...... 5 BARACLUDE...... 21 BIVIGAM...... 47 aspirin ec low strength...... 5 BAVENCIO...... 19 bleomycin sulfate...... 17 aspirin low dose...... 5 BAXDELA...... 11 BLINCYTO...... 19 aspirin-dipyridamole er...... 27 BAYER ASPIRIN...... 5 blisovi 24 fe...... 42 atazanavir sulfate...... 23 BAYER ASPIRIN EC LOW blisovi fe 1.5/30...... 42 atenolol...... 28 DOSE...... 5 blisovi fe 1/20...... 42 atenolol-chlorthalidone...... 29 BD AUTOSHIELD DUO PEN BOOSTRIX...... 47 atomoxetine hcl...... 31 NEEDLES...... 49 bosentan...... 55 atorvastatin calcium...... 30 BD ULTRA-FINE INSULIN BOSULIF...... 18 atovaquone...... 19 SYRINGES...... 49 BOTOX...... 49 atovaquone-proguanil hcl...... 19 BD ULTRA-FINE PEN bp vit 3...... 35 atropine sulfate...... 36, 52 NEEDLES...... 49 b-plex...... 35 ATROVENT HFA...... 55 BD VEO INSULIN SYR U/F b-plex plus...... 35 aubra...... 41 1/2UNIT...... 49 BREATHE EASE LARGE...... 49 aubra eq...... 41 bekyree...... 42 BREATHE EASE MEDIUM...... 49 AUGMENTIN...... 10 BELEODAQ...... 18 BREATHE EASE SMALL...... 49 aurovela 1.5/30...... 42 BELSOMRA...... 57 BREO ELLIPTA...... 54 aurovela 1/20...... 42 benazepril hcl...... 27 briellyn...... 42 aurovela 24 fe...... 42 benazepril-hydrochlorothiazide. 29 BRILINTA...... 27 aurovela fe 1.5/30...... 42 BENDEKA...... 16 brimonidine tartrate...... 52 aurovela fe 1/20...... 42 BENEFIX...... 26 brinzolamide...... 52 AUVI-Q...... 55 benzalkonium chloride...... 49 BRIVIACT...... 11 AVASTIN...... 19 BENZNIDAZOLE...... 20 bromfenac sodium (once-daily).53 aviane...... 42 benzonatate...... 56 bromocriptine mesylate...... 20 avidoxy...... 11 benzoyl peroxide-erythromycin. 32 BROVANA...... 55 AVONEX PEN...... 32 benztropine mesylate...... 20 budesonide...... 48, 54 AVONEX PREFILLED...... 32 BEPREVE...... 52 budesonide er...... 48 AVSOLA...... 46 BERINERT...... 46 bumetanide...... 30 ayuna...... 42 beser...... 39 buprenorphine...... 6 azacitidine...... 17 BESIVANCE...... 53 buprenorphine hcl...... 8 AZASAN...... 46 betamethasone dipropionate.... 39 buprenorphine hcl-naloxone AZASITE...... 52 betamethasone dipropionate hcl...... 8 azathioprine...... 46 aug...... 39 bupropion hcl...... 13 azathioprine sodium...... 46 betamethasone sod phos & bupropion hcl er (smoking det)... 8 azelaic acid...... 32 acet...... 39 bupropion hcl er (sr)...... 12 azelastine hcl...... 52, 54 ...... 39 bupropion hcl er (xl)...... 13 azelastine-fluticasone...... 56 BETASERON...... 32 buspirone hcl...... 23 AZELEX...... 32 betaxolol hcl...... 28, 52 busulfan...... 16 azithromycin...... 10 bethanechol chloride...... 39 butalbital-acetaminophen...... 6 AZOPT...... 52 BETHKIS...... 55 butalbital-apap-caff-cod...... 6 aztreonam...... 8 BETIMOL...... 52 butalbital-apap-caffeine...... 5, 6 azurette...... 42 bexarotene...... 19 butalbital-asa-caff-codeine...... 6 b-6 folic acid...... 35 BEXSERO...... 47 butalbital-aspirin-caffeine...... 5 bac...... 5 bicalutamide...... 16 butorphanol tartrate...... 6, 7 bacitracin...... 8, 51 BICILLIN L-A...... 10 BYDUREON BCISE bacitracin-polymyxin b...... 51 BIJUVA...... 42 AUTOINJECTOR...... 24 bacitra-neomycin-polymyxin-hc 51 BIKTARVY...... 22 BYETTA 10 MCG PEN...... 24 baclofen...... 56 bimatoprost...... 53 BYETTA 5 MCG PEN...... 24 BAFIERTAM...... 32 biocel...... 35 BYSTOLIC...... 28 bal in oil...... 49 bisacodyl ec...... 37 cabergoline...... 41 balsalazide disodium...... 48 bisoprolol fumarate...... 28 CABLIVI...... 27 balziva...... 42 bisoprolol-hydrochlorothiazide.. 29 CABOMETYX...... 18 BANZEL...... 12 bivalirudin trifluoroacetate...... 26 caffeine citrate...... 31

59 calcipotriene...... 32, 33 cefpodoxime proxetil...... 10 CIPRO HC...... 53 calcipotriene-betameth diprop...33 cefprozil...... 10 CIPRODEX...... 53 calcitonin (salmon)...... 49 ceftazidime...... 10 ciprofloxacin hcl...... 11, 53 calcitriol...... 33, 49 ceftazidime and dextrose...... 10 ciprofloxacin in d5w...... 11 calcium acetate...... 35 ceftriaxone sodium...... 10 ciprofloxacin-dexamethasone... 53 calcium acetate (phos binder)...35 ceftriaxone sodium in dextrose. 10 cisplatin...... 16 calcium chloride...... 33 ceftriaxone sodium-dextrose.....10 citalopram hydrobromide...... 13 calcium gluconate...... 33 cefuroxime axetil...... 10 citroma...... 37 camila...... 44 celecoxib...... 5 cladribine...... 17 camrese...... 42 CELONTIN...... 11 claravis...... 33 camrese lo...... 42 cephalexin...... 10 clarithromycin...... 10 candesartan cilexetil...... 27 CEPROTIN...... 26 clarithromycin er...... 10 candesartan cilexetil-hctz...... 29 CEQUR SIMPLICITY 2U...... 24 clearlax...... 37 CAPASTAT SULFATE...... 16 CERDELGA...... 38 clemastine fumarate...... 54 capecitabine...... 16 cetirizine hcl...... 54 CLENPIQ...... 37 CAPRELSA...... 18 cevimeline hcl...... 32 CLEVER CHOICE HOLDING captopril...... 27 CHANTIX...... 8 CHAMBER...... 49 captopril-hydrochlorothiazide.... 29 CHANTIX CONTINUING clindacin etz...... 33 CARBAGLU...... 33 MONTH PAK...... 8 clindacin-p...... 33 carbamazepine...... 12 CHANTIX STARTING MONTH clindamycin hcl...... 8 carbamazepine er...... 12 PAK...... 8 clindamycin palmitate hcl...... 8 carbidopa...... 20 charlotte 24 fe...... 42 clindamycin phosphate..... 8, 9, 33 carbidopa-levodopa...... 20 chateal...... 42 clindamycin phosphate in d5w.... 8 carbidopa-levodopa er...... 20 chateal eq...... 42 clindamycin phosphate- carbidopa-levodopa- CHEMET...... 35 benzoyl peroxide...... 33 entacapone...... 20 CHEMSTRIP UGK...... 24 clindamycin-tretinoin...... 33 carbinoxamine maleate...... 54 chloramphenicol sod succinate...8 CLINPRO 5000...... 32 carboplatin...... 16 chlordiazepoxide hcl...... 23 clobazam...... 11 CARIMUNE NF...... 47 chlordiazepoxide-amitriptyline...13 clobetasol prop emollient base. 39 carisoprodol...... 56 chlorhexidine gluconate...... 32 clobetasol propionate...... 39 carmustine...... 16 chloroquine phosphate...... 20 clobetasol propionate e...... 39 carteolol hcl...... 52 chlorpromazine hcl...... 21 clobetasol propionate emulsion 39 cartia xt...... 28 chlorthalidone...... 30 ...... 39 carvedilol...... 28 chlorzoxazone...... 56 clodan...... 39 carvedilol phosphate er...... 28 CHOLBAM...... 38 clofarabine...... 17 cascara sagrada...... 37 cholestyramine...... 30 clomipramine hcl...... 13 caspofungin acetate...... 14 cholestyramine light...... 30 clonazepam...... 23 cavarest...... 32 chorionic gonadotropin...... 41 clonidine...... 27 CAYA...... 49 chromic chloride...... 33 clonidine hcl...... 27 caziant...... 42 ciclodan...... 14 clonidine hcl er...... 31 cefaclor...... 9 ciclopirox...... 14 clopidogrel bisulfate...... 27 cefaclor er...... 9 ciclopirox olamine...... 14 clorazepate dipotassium...... 23 cefadroxil...... 9 cidofovir...... 21 clotrimazole...... 14 cefazolin sodium...... 9 cilostazol...... 27 clotrimazole-betamethasone.....14 cefazolin sodium-dextrose.... 9, 10 CIMDUO...... 22 clovique...... 35 cefdinir...... 10 cimetidine...... 37 clozapine...... 21 cefepime hcl...... 10 cimetidine hcl...... 36 COAGADEX...... 26 cefepime-dextrose...... 10 CIMZIA...... 46 coal tar...... 33 cefixime...... 10 CIMZIA PREFILLED KIT...... 46 COARTEM...... 20 cefotaxime sodium...... 10 CIMZIA STARTER KIT...... 46 cod liver oil...... 35 cefotetan disodium...... 10 cinacalcet hcl...... 49 codeine sulfate...... 7 cefotetan disodium-dextrose.....10 CINRYZE...... 46 colchicine...... 15 cefoxitin sodium...... 10 CIPRO...... 11 colchicine-probenecid...... 15

60 colesevelam hcl...... 30 cyclafem 1/35...... 42 desmopressin acetate spray..... 41 colestipol hcl...... 30 cyclafem 7/7/7...... 42 desogestrel-ethinyl estradiol..... 42 colistimethate sodium (cba)...... 9 cyclobenzaprine hcl...... 56 desonide...... 39 COMBIGAN...... 52 cyclopentolate hcl...... 52 desoximetasone...... 40 COMBIPATCH...... 42 cyclophosphamide...... 16 desvenlafaxine succinate er...... 13 COMBIVENT RESPIMAT...... 56 cycloserine...... 16 dexamethasone...... 40 COMETRIQ...... 18 cyclosporine...... 46 dexamethasone intensol...... 40 COMFORT TOUCH cyclosporine modified...... 46 dexamethasone sod ALCOHOL PREP...... 49 cyproheptadine hcl...... 54 phosphate pf...... 40 COMPACT SPACE CYRAMZA...... 19 dexamethasone sodium CHAMBER/LG MASK...... 49 cyred...... 42 phosphate...... 40, 53 COMPACT SPACE cyred eq...... 42 dexchlorpheniramine maleate...54 CHAMBER/MED MASK...... 49 CYSTAGON...... 38 DEXILANT...... 37 COMPACT SPACE CYSTARAN...... 52 dexmedetomidine hcl...... 49 CHAMBER/SM MASK...... 49 cytarabine...... 17 dexmedetomidine hcl in nacl.....49 COMPLERA...... 22 cytarabine (pf)...... 17 dexmethylphenidate hcl...... 31 compro...... 14 CYTOGAM...... 47 dexmethylphenidate hcl er...... 31 CONDYLOX...... 33 dacarbazine...... 16 dexrazoxane hcl...... 17 constulose...... 37 dactinomycin...... 17 dextroamphetamine sulfate...... 31 CONTOUR CONTROL dalfampridine er...... 32 dextroamphetamine sulfate er.. 31 SOLUTION...... 24 DALIRESP...... 55 dextrose...... 33 CONTOUR MONITOR danazol...... 41 dextrose in lactated ringers...... 33 DEVICE...... 24 dantrolene sodium...... 56 dextrose-nacl...... 33 CONTOUR MONITOR KIT dapsone...... 16, 33 dextrose-sodium chloride...... 34 W/DEVICE...... 24 DAPTACEL...... 47 DIACOMIT...... 11 CONTOUR NEXT CONTROL daptomycin...... 9 diazepam...... 11, 23 SOLUTION...... 24 darifenacin hydrobromide er..... 38 diazepam intensol...... 23 CONTOUR NEXT EZ KIT DARZALEX...... 19 diazoxide...... 25 W/DEVICE...... 24 dasetta 1/35...... 42 diclofenac potassium...... 5 CONTOUR NEXT LINK...... 24 dasetta 7/7/7...... 42 diclofenac sodium...... 5, 17, 53 CONTOUR NEXT MONITOR daunorubicin hcl...... 17 diclofenac sodium er...... 5 KIT W/DEVICE...... 24 daysee...... 42 diclofenac-misoprostol...... 5 CONTOUR NEXT ONE KIT...... 24 DAYTRANA...... 31 dicloxacillin sodium...... 10 CONTOUR NEXT TEST DEBACTEROL...... 32 dicyclomine hcl...... 36 STRIPS...... 24 deblitane...... 44 DIFICID...... 10 CONTOUR TEST STRIPS...... 24 decitabine...... 17 diflunisal...... 5 COPAXONE...... 32 deferasirox...... 35 digitek...... 29 CORIFACT...... 26 deferasirox granules...... 35 digox...... 29 CORLANOR...... 29 deferiprone...... 35 digoxin...... 29 CORTIFOAM...... 48 deferoxamine mesylate...... 49 dihydroergotamine mesylate.....15 CORTISPORIN...... 9 delyla...... 42 DILANTIN...... 12 CORTISPORIN-TC...... 53 demeclocycline hcl...... 11 DILATRATE-SR...... 31 COTELLIC...... 18 DEMSER...... 29 diltiazem hcl...... 28 CREON...... 38 DENAVIR...... 22 diltiazem hcl er...... 28 CRESEMBA...... 14 DENTA 5000 PLUS...... 32 diltiazem hcl er beads...... 28 CRIXIVAN...... 23 DENTAGEL...... 32 diltiazem hcl er coated beads... 28 cromolyn sodium...... 36, 52, 55 DEPO-MEDROL...... 39 dilt-xr...... 28 crotan...... 20 DEPO-SUBQ PROVERA 104...44 dimenhydrinate...... 14 cryselle-28...... 42 DESCOVY...... 22 dimethyl fumarate...... 32 curity sterile saline...... 39 desipramine hcl...... 13 dimethyl fumarate starter pack..32 CUVITRU...... 47 desloratadine...... 54 DIPENTUM...... 48 CUVPOSA...... 36 desmopressin ace spray refrig..41 diphen...... 54 cyanocobalamin...... 35 desmopressin acetate...... 41 diphenhydramine hcl...... 54

61 diphenoxylate-atropine...... 36 elinest...... 42 ergoloid mesylates...... 49 DIPHTHERIA-TETANUS ELIQUIS...... 26 ergotamine-caffeine...... 15 TOXOIDS DT...... 47 ELIQUIS DVT/PE STARTER ERIVEDGE...... 18 dipyridamole...... 27 PACK...... 26 erlotinib hcl...... 18 disopyramide phosphate...... 27 ELITEK...... 19 errin...... 44 disulfiram...... 8 ELIXOPHYLLIN...... 55 ertapenem sodium...... 10 divalproex sodium...... 23 ELLA...... 44 ery...... 33 divalproex sodium er...... 23 ELMIRON...... 39 erythromycin...... 10, 33, 52 DIVIGEL...... 42 ELOCTATE...... 26 erythromycin base...... 10 dobutamine hcl...... 29 eluryng...... 42 erythromycin ethylsuccinate...... 10 dobutamine in d5w...... 29 EMCYT...... 16 escitalopram oxalate...... 13 docetaxel...... 17 EMGALITY...... 15 esmolol hcl...... 28 dofetilide...... 27 EMGALITY (300 MG DOSE).... 15 esmolol hcl-sodium chloride...... 28 donepezil hcl...... 12 emoquette...... 42 esomeprazole sodium...... 37 dopamine hcl...... 29 EMPLICITI...... 19 estarylla...... 42 dopamine in d5w...... 29 EMSAM...... 13 estazolam...... 23 dorzolamide hcl...... 53 emtricitabine...... 22 estradiol...... 42 dorzolamide hcl-timolol mal...... 53 emtricitabine-tenofovir df...... 22 estradiol valerate...... 42 dorzolamide hcl-timolol mal pf.. 53 EMTRIVA...... 22 estradiol-norethindrone acet..... 42 dotti...... 42 EMVERM...... 19 eszopiclone...... 56 doxazosin mesylate...... 27 enalapril maleate...... 27 ethacrynate sodium...... 30 doxepin hcl...... 13, 33, 57 enalaprilat...... 27 ethacrynic acid...... 30 doxercalciferol...... 49 enalapril-hydrochlorothiazide.... 29 ethambutol hcl...... 16 doxorubicin hcl...... 17 ENBREL...... 46 ethosuximide...... 11 doxorubicin hcl liposomal...... 17 ENBREL MINI...... 46 ethyl chloride...... 7 doxy 100...... 11 ENBREL SURECLICK...... 46 ethynodiol diac-eth estradiol..... 42 doxycycline hyclate...... 11 ENCARE...... 39 ETHYOL...... 17 doxycycline monohydrate...... 11 endocet...... 7 etodolac...... 5 dronabinol...... 14 ENGERIX-B...... 47 etodolac er...... 5 droperidol...... 14 ENHERTU...... 19 etonogestrel-ethinyl estradiol.... 42 DROPLET MICRON...... 49 enoxaparin sodium...... 26 etoposide...... 18 drospiren-eth estrad-levomefol. 42 enpresse-28...... 42 euthyrox...... 45 drospirenone-ethinyl estradiol...42 enskyce...... 42 EVAMIST...... 42 DROXIA...... 17 entacapone...... 20 everolimus...... 18, 46 DUAVEE...... 42 entecavir...... 21 EVOTAZ...... 23 duloxetine hcl...... 13 ENTRESTO...... 29 EVRYSDI...... 38 DUPIXENT...... 33 enulose...... 37 exemestane...... 18 duramorph...... 7 EPCLUSA...... 21 ezetimibe...... 30 DUREZOL...... 53 ephedrine sulfate...... 29 ezetimibe-simvastatin...... 30 dutasteride...... 38 EPIDIOLEX...... 11 fabb...... 35 dutasteride-tamsulosin hcl...... 38 EPIDUO FORTE...... 33 FABRAZYME...... 38 EASIVENT...... 49 epinastine hcl...... 52 falmina...... 42 easygel...... 32 epinephrine...... 55 famciclovir...... 22 ec-naproxen...... 5 epinephrine (anaphylaxis)...... 55 famotidine...... 37 econazole nitrate...... 14 epinephrine pf...... 29 famotidine premixed...... 37 ED-SPAZ...... 36 epirubicin hcl...... 17 FANAPT...... 21 EDURANT...... 22 epitol...... 12 FANAPT TITRATION PACK..... 21 efavirenz...... 22 EPIVIR HBV...... 21 FARXIGA...... 24 efavirenz-emtricitab-tenofovir....22 eplerenone...... 30 FARYDAK...... 18 efavirenz-lamivudine-tenofovir.. 22 epoprostenol sodium...... 55 fa-vitamin b-6-vitamin b-12...... 35 effer-k...... 34 eptifibatide...... 27 fayosim...... 42 ELAPRASE...... 38 ERBITUX...... 19 FC FEMALE CONDOM...... 50 eletriptan hydrobromide...... 15 ergocalciferol...... 35 FC2 FEMALE CONDOM...... 50

62 febuxostat...... 15 FLUORIDEX...... 32 GAMIFANT...... 47 FEIBA...... 26 fluoridex daily renewal...... 32 GAMMAGARD...... 47 felbamate...... 12 FLUORIDEX ENHANCED GAMMAGARD S/D LESS IGA..47 felodipine er...... 28 WHITENING...... 32 GAMMAKED...... 47 FEMCAP...... 50 FLUORIDEX SENSITIVITY GAMMAPLEX...... 47 femynor...... 42 RELIEF...... 32 GAMUNEX-C...... 47 fenofibrate...... 30 fluoritab...... 34 ganciclovir sodium...... 21 fenofibrate micronized...... 30 fluorometholone...... 53 GARDASIL 9...... 48 fenofibric acid...... 30 FLUOROPLEX...... 17 gatifloxacin...... 53 fenoprofen calcium...... 5 fluorouracil...... 17 GATTEX...... 36 fentanyl...... 6 FLUOROURACIL...... 17 gavilax...... 37 fentanyl citrate...... 7 fluoxetine hcl...... 13 gavilyte-c...... 37 ferocon...... 34 fluoxetine hcl (pmdd)...... 13 gavilyte-g...... 37 ferotrinsic...... 34 fluphenazine decanoate...... 21 gavilyte-h...... 37 ferraplus 90...... 34 fluphenazine hcl...... 21 gavilyte-n with flavor pack...... 37 ferrocite plus...... 34 flurbiprofen...... 5 GAZYVA...... 19 FETZIMA...... 13 flurbiprofen sodium...... 53 GELNIQUE...... 38 FETZIMA TITRATION...... 13 flutamide...... 16 gemcitabine hcl...... 17 finasteride...... 38 fluticasone propionate...... 40, 54 gemfibrozil...... 30 flac...... 53 fluticasone-salmeterol...... 54 gemmily...... 42 FLAREX...... 53 FLUTICASONE- generlac...... 37 flavoxate hcl...... 38 SALMETEROL...... 54 gengraf...... 46 FLEBOGAMMA DIF...... 47 fluvoxamine maleate...... 13 gentak...... 51 flecainide acetate...... 27 fluvoxamine maleate er...... 13 gentamicin in saline...... 8 FLEXICHAMBER ADULT FLUZONE HIGH-DOSE gentamicin sulfate...... 8, 51 MASK/SMALL...... 50 QUADRIVALENT...... 47 gentle laxative...... 37 FLEXICHAMBER CHILD FLUZONE QUADRIVALENT.... 48 GENVOYA...... 22 MASK/LARGE...... 50 FML...... 53 GILENYA...... 32 FLEXICHAMBER CHILD folbee...... 35 GILOTRIF...... 18 MASK/SMALL...... 50 folbee plus...... 35 glatiramer acetate...... 32 FLOVENT DISKUS...... 54 folic acid...... 35 glatopa...... 32 FLOVENT HFA...... 54 FOLOTYN...... 17 GLEOSTINE...... 16 floxuridine...... 17 folplex 2.2...... 35 glimepiride...... 24 FLUAD...... 47 foltrin...... 34 glipizide er...... 24 FLUAD QUADRIVALENT...... 47 fomepizole...... 50 glipizide ir...... 24 FLUARIX QUADRIVALENT...... 47 fondaparinux sodium...... 26 glipizide xl...... 24 FLUBLOK QUADRIVALENT.....47 FORTEO...... 49 glipizide-metformin hcl...... 24 FLUCELVAX fosamprenavir calcium...... 23 glucagon emergency kit...... 25 QUADRIVALENT...... 47 fosaprepitant dimeglumine...... 14 GLUCAGON EMERGENCY fluconazole...... 14 fosfomycin tromethamine...... 9 KIT...... 25 fluconazole in sodium chloride..14 fosinopril sodium...... 27 glyburide...... 24 flucytosine...... 14 fosinopril sodium-hctz...... 29 glyburide micronized...... 24 fludarabine phosphate...... 17 fosphenytoin sodium...... 12 glyburide-metformin...... 24 fludrocortisone acetate...... 40 FOSRENOL...... 35 glycine...... 39 FLULAVAL QUADRIVALENT... 47 fulvestrant...... 16 glycine urologic...... 39 flumazenil...... 50 furosemide...... 30 glycolax...... 37 FLUMIST QUADRIVALENT...... 47 FUZEON...... 23 glycopyrrolate...... 36 flunisolide...... 54 fyavolv...... 42 glycopyrrolate pf...... 36 fluocinolone acetonide...... 40, 54 FYCOMPA...... 12 glydo...... 7 fluocinolone acetonide body..... 40 gabapentin...... 11 GLYXAMBI...... 24 fluocinolone acetonide scalp.....40 galantamine hydrobromide...... 12 gnp aspirin low dose...... 5 fluocinonide...... 40 galantamine hydrobromide er... 12 goodsense aspirin low dose...... 5 fluocinonide emulsified base.....40 GAMASTAN...... 47 goodsense nicotine...... 8

63 GRALISE...... 31 HUMIRA PEDIATRIC iclevia...... 42 granisetron hcl...... 14 CROHNS START...... 46 ICLUSIG...... 18 griseofulvin microsize...... 14 HUMIRA PEN...... 46 idarubicin hcl...... 17 griseofulvin ultramicrosize...... 14 HUMIRA PEN-CD/UC/HS ifosfamide...... 16 guanfacine hcl...... 27 STARTER...... 46 ILARIS...... 47 guanfacine hcl er...... 31 HUMIRA PEN-PEDIATRIC UC ILEVRO...... 53 GUANIDINE HCL...... 15 START...... 46 imatinib mesylate...... 18 GYNAZOLE-1...... 14 HUMIRA PEN-PS/UV/ADOL IMBRUVICA...... 18 habitrol...... 8 HS START...... 46 imipenem-cilastatin...... 10 hailey 1.5/30...... 42 HUMIRA PEN-PSOR/UVEIT imipramine hcl...... 13 hailey 24 fe...... 42 STARTER...... 46 imipramine pamoate...... 13 hailey fe 1.5/30...... 42 HUMULIN 70/30 KWIKPEN...... 25 imiquimod...... 33 hailey fe 1/20...... 42 HUMULIN 70/30 VIAL...... 25 IMPAVIDO...... 20 HALAVEN...... 17 HUMULIN N KWIKPEN...... 25 inavix...... 5 halcinonide...... 40 HUMULIN N VIAL...... 25 incassia...... 44 halobetasol propionate...... 40 HUMULIN R U-500 KWIKPEN..25 INCRELEX...... 41 haloperidol...... 21 HUMULIN R U-500 VIAL...... 25 INCRUSE ELLIPTA...... 55 ...... 21 HUMULIN R VIAL...... 25 indapamide...... 30 haloperidol lactate...... 21 HYCAMTIN...... 18 indomethacin...... 5 HARVONI...... 21 hydralazine hcl...... 31 indomethacin er...... 5 HAVRIX...... 48 hydrochlorothiazide...... 30 indomethacin sodium...... 5 heather...... 44 hydrocodone bitartrate er...... 6 INFANRIX...... 48 HEMLIBRA...... 26 hydrocodone-acetaminophen..... 7 INFLECTRA...... 46 hemocyte-f...... 34 hydrocodone-homatropine...... 56 INLYTA...... 18 HEMOFIL M...... 26 hydrocodone-ibuprofen...... 7 INPEN 100-BLUE-LILLY...... 24 HEPAGAM B...... 47 hydrocortisone...... 40, 48 INPEN 100-BLUE-NOVO...... 24 heparin (porcine) in nacl...... 26 hydrocortisone (perianal)...... 48 INPEN 100-GRAY-LILLY...... 24 heparin lock flush...... 50 hydrocortisone ace-pramoxine..48 INPEN 100-GREY-NOVO...... 24 heparin sod (porcine) in d5w.....26 hydrocortisone butyrate...... 40 INPEN 100-PINK-LILLY...... 24 heparin sodium (porcine)...... 26 hydrocortisone valerate...... 40 INPEN 100-PINK-NOVO...... 24 heparin sodium (porcine) pf...... 26 hydrocortisone-acetic acid...... 54 INSPIREASE RESERVOIR heparin sodium lock flush...... 50 hydromet...... 56 BAGS...... 50 HEPLISAV-B...... 48 hydromorphone hcl...... 7 INSULIN PEN NEEDLES...... 50 HERCEPTIN...... 19 hydromorphone hcl er...... 6 INSULIN SYRINGES...... 50 HERCEPTIN HYLECTA...... 19 hydromorphone hcl pf...... 7 INTELENCE...... 22 hetastarch-nacl...... 50 hydroxocobalamin acetate...... 35 INTRAROSA...... 41 HETLIOZ...... 57 hydroxychloroquine sulfate...... 20 INTRON A...... 22 HIBERIX...... 48 hydroxyprogesterone caproate. 44 introvale...... 42 HIZENTRA...... 47 hydroxyurea...... 17 INVEGA SUSTENNA...... 21 homatropaire...... 52 hydroxyzine hcl...... 23 INVEGA TRINZA...... 21 HUMALOG KWIKPEN...... 25 hydroxyzine pamoate...... 23 INVIRASE...... 23 HUMALOG MIX 50/50 hyoscyamine sulfate...... 36 iodine strong...... 34 KWIKPEN...... 25 hyoscyamine sulfate sl...... 36 iodine tincture...... 9 HUMALOG MIX 50/50 VIAL...... 25 HYPERHEP B...... 47 IOPIDINE...... 53 HUMALOG MIX 75/25 HYPERRHO S/D...... 47 IPOL...... 48 KWIKPEN...... 25 HYQVIA...... 47 ipratropium bromide...... 55 HUMALOG MIX 75/25 VIAL...... 25 HYSINGLA ER...... 6 ipratropium-albuterol...... 56 HUMALOG U-100 JUNIOR ibandronate sodium...... 49 irbesartan...... 27 KWIKPEN...... 25 IBRANCE...... 18 irbesartan-hydrochlorothiazide..29 HUMALOG VIAL...... 25 ibuprofen...... 5 irinotecan hcl...... 17 HUMATE-P...... 26 ibuprofen lysine...... 5 ISENTRESS...... 22 HUMIRA...... 46 ibutilide fumarate...... 27 ISENTRESS HD...... 22 icatibant acetate...... 46 isibloom...... 42

64 isoniazid...... 16 klor-con 10...... 34 leuprolide acetate...... 45 isoproterenol hcl...... 55 klor-con m10...... 34 levalbuterol hcl...... 55 isosorbide dinitrate...... 31 KLOR-CON M15...... 34 LEVEMIR U-100 FLEXTOUCH.25 isosorbide mononitrate...... 31 klor-con m20...... 34 LEVEMIR U-100 VIAL...... 25 isosorbide mononitrate er...... 31 klor-con/ef...... 34 levetiracetam...... 11 isotretinoin...... 33 KOATE...... 26 levetiracetam er...... 11 ISTODAX (OVERFILL)...... 17 KOATE-DVI...... 26 levetiracetam in nacl...... 11 itraconazole...... 14 KOGENATE FS...... 26 levobunolol hcl...... 53 ivermectin...... 19 KORLYM...... 41 levocarnitine...... 34 IXEMPRA KIT...... 17 KOSELUGO...... 18 levocarnitine sf...... 34 jaimiess...... 42 KOVALTRY...... 26 levocetirizine dihydrochloride....54 JAKAFI...... 18 k-prime...... 34 levofloxacin...... 11, 53 jantoven...... 26 k-tan plus...... 34 levofloxacin in d5w...... 11 JANUMET...... 24 kurvelo...... 43 levoleucovorin calcium...... 17 JANUMET XR...... 24 KUVAN...... 38 levoleucovorin calcium pf...... 17 JANUVIA...... 24 KYLEENA...... 44 levonest...... 43 JARDIANCE...... 24 KYPROLIS...... 18 levonorgest-eth est & eth est.... 43 jasmiel...... 43 labetalol hcl...... 28 levonorgest-eth estrad 91-day.. 43 jencycla...... 44 lactated ringers...... 34, 50 levonorgestrel...... 45 JENTADUETO...... 24 lactic acid...... 33 levonorgestrel-ethinyl estrad.....43 JENTADUETO XR...... 24 lactic acid e...... 33 levonorg-eth estrad triphasic.....43 JEVTANA...... 18 lactulose...... 37 levora 0.15/30 (28)...... 43 jinteli...... 43 lactulose encephalopathy...... 37 levorphanol tartrate...... 6 jolessa...... 43 lamivudine...... 21, 22 levo-t...... 45 J-TIP KIT W/VIAL ADAPTERS. 50 lamivudine-zidovudine...... 22 levothyroxine sodium...... 45 juleber...... 43 lamotrigine...... 12 levoxyl...... 45 JULUCA...... 22 lamotrigine er...... 12 LEXIVA...... 23 junel 1.5/30...... 43 lamotrigine starter kit-blue...... 12 lidocaine...... 7 junel 1/20...... 43 lamotrigine starter kit-green...... 12 lidocaine hcl...... 7 junel fe 1.5/30...... 43 lamotrigine starter kit-orange.... 12 lidocaine hcl (cardiac)...... 28 junel fe 1/20...... 43 LANCETS...... 24 lidocaine hcl (cardiac) pf...... 28 junel fe 24...... 43 lansoprazole...... 37 lidocaine hcl (pf)...... 7 KADCYLA...... 19 lanthanum carbonate...... 35 lidocaine hcl urethral/mucosal.....7 KALETRA...... 23 LANTUS SOLOSTAR...... 25 lidocaine in d5w...... 28 kalliga...... 43 LANTUS U-100 VIAL...... 25 lidocaine viscous hcl...... 7 KALYDECO...... 55 lapatinib ditosylate...... 18 lidocaine-prilocaine...... 7 KANJINTI...... 19 larin 1.5/30...... 43 LIDOCAINE-TETRACAINE...... 7 KANUMA...... 38 larin 1/20...... 43 LILETTA (52 MG)...... 45 kariva...... 43 larin 24 fe...... 43 lillow...... 43 kcl in dextrose-nacl...... 34 larin fe 1.5/30...... 43 lincomycin hcl...... 9 kcl-lactated ringers-d5w...... 34 larin fe 1/20...... 43 lindane...... 20 kedbumin...... 50 larissia...... 43 linezolid...... 9 kelnor 1/35...... 43 LASTACAFT...... 52 linezolid in sodium chloride...... 9 kelnor 1/50...... 43 latanoprost...... 53 LINZESS...... 37 KERYDIN...... 14 LATUDA...... 21 liothyronine sodium...... 45 ketoconazole...... 14 layolis fe...... 43 lisinopril...... 27 ketoprofen...... 5 leena...... 43 lisinopril-hydrochlorothiazide.....29 ketoprofen er...... 5 leflunomide...... 47 lithium...... 23 ketorolac tromethamine...... 5, 53 LENVIMA...... 18 lithium carbonate...... 24 KETOSTIX...... 24 lessina...... 43 lithium carbonate er...... 24 KINERET...... 46 letrozole...... 18 LIVALO...... 30 KINRIX...... 48 leucovorin calcium...... 17 lojaimiess...... 43 klor-con...... 34 LEUKERAN...... 16 LONSURF...... 17

65 loperamide hcl...... 36 megestrol acetate...... 45 metoclopramide hcl...... 14 lopinavir-ritonavir...... 23 MEKINIST...... 18 metolazone...... 30 lorazepam...... 23 melodetta 24 fe...... 43 metoprolol succinate er...... 28 lorazepam intensol...... 23 meloxicam...... 5 metoprolol tartrate...... 28 loryna...... 43 melphalan...... 16 metoprolol-hydrochlorothiazide.29 losartan potassium...... 27 melphalan hcl...... 16 metronidazole...... 9, 33 losartan potassium-hctz...... 29 memantine hcl...... 12 metronidazole in nacl...... 9 loteprednol etabonate...... 53 memantine hcl er...... 12 metyrosine...... 29 lovastatin...... 30 MENACTRA...... 48 mexiletine hcl...... 28 low-ogestrel...... 43 MENEST...... 43 MIACALCIN...... 49 loxapine succinate...... 21 MENQUADFI...... 48 mibelas 24 fe...... 43 lo-zumandimine...... 43 MENVEO...... 48 micafungin sodium...... 15 LUMIGAN...... 53 MEPSEVII...... 38 miconazole 3...... 15 LUMIZYME...... 38 mercaptopurine...... 17 MICRHOGAM ULTRA- LUPRON DEPOT (1-MONTH)..45 meropenem...... 10 FILTERED PLUS...... 47 LUPRON DEPOT (3-MONTH)..45 merzee...... 43 MICROCHAMBER...... 50 LUPRON DEPOT (4-MONTH) mesalamine...... 48 microgestin 1.5/30...... 43 INTRAMUSCULAR KIT 30MG..45 mesalamine er oral capsule microgestin 1/20...... 43 LUPRON DEPOT (6-MONTH) 0.375 gm...... 48 microgestin 24 fe...... 43 INTRAMUSCULAR KIT 45MG..45 mesalamine-cleanser...... 48 microgestin fe 1.5/30...... 43 LUPRON DEPOT-PED (1- mesna...... 19 microgestin fe 1/20...... 43 MONTH)...... 45 MESNEX...... 19 midodrine hcl...... 27 LUPRON DEPOT-PED (3- metaxalone...... 56 mifepristone...... 41 MONTH)...... 45 metformin hcl er...... 25 miglitol...... 25 lutera...... 43 metformin hcl ir...... 25 miglustat...... 38 lyleq...... 45 methadone hcl...... 6 mili...... 43 lyllana...... 43 methadone hcl intensol...... 6 milrinone lactate...... 29 LYNPARZA...... 18 methadose...... 6 milrinone lactate in dextrose..... 29 lysiplex plus...... 35 methadose sugar-free...... 6 mimvey...... 43 LYSODREN...... 45 methazolamide...... 30 mineral oil heavy...... 37 lyza...... 45 methenamine hippurate...... 9 MINOCIN...... 11 mafenide acetate...... 9 methergine...... 50 minocycline hcl...... 11 magnesium chloride...... 34 methimazole...... 46 minoxidil...... 31 magnesium citrate...... 37 METHITEST...... 41 MIRENA (52 MG)...... 45 magnesium sulfate...... 34 methocarbamol...... 56 mirtazapine...... 13 magnesium sulfate in d5w...... 34 methotrexate...... 46 MIRVASO...... 33 MAKENA...... 45 methotrexate sodium...... 46 misoprostol...... 37 malathion...... 20 methotrexate sodium (pf)...... 46 mitigo...... 6 maprotiline hcl...... 13 methoxsalen rapid...... 33 mitomycin...... 17 marlissa...... 43 methscopolamine bromide...... 36 mitoxantrone hcl...... 17 MARPLAN...... 13 methyldopa...... 27 mm clearlax...... 37 MARQIBO...... 17 methyldopa- M-M-R II...... 48 MATULANE...... 16 hydrochlorothiazide...... 29 modafinil...... 57 matzim la...... 28 methylergonovine maleate...... 50 moexipril hcl...... 27 MAVYRET...... 21 methylphenidate hcl...... 31 molindone hcl...... 21 MAXICOMFORT SYR 27G X methylphenidate hcl er...... 31 mometasone furoate...... 40, 54 1/2"...... 50 methylphenidate hcl er (cd)...... 31 mondoxyne nl...... 11 MAYZENT...... 32 methylphenidate hcl er (la)...... 31 monoject flush syringe...... 50 MAYZENT STARTER PACK.... 32 methylphenidate hcl er (xr)...... 31 monoject sodium chloride flush.50 meclizine hcl...... 14 methylprednisolone...... 40 mono-linyah...... 43 meclofenamate sodium...... 5 methylprednisolone acetate...... 40 montelukast sodium...... 54 medroxyprogesterone acetate.. 45 methylprednisolone sodium morgidox...... 11 mefloquine hcl...... 20 succ...... 40 morphine sulfate...... 7

66 morphine sulfate (concentrate)... 7 neomycin-polymyxin-hc...... 52, 54 norethindrone-eth estradiol...... 43 morphine sulfate (pf)...... 7 neo-polycin...... 52 norethin-eth estradiol-fe...... 43 morphine sulfate er...... 6 neo-polycin hc...... 52 norgestimate-eth estradiol...... 43 morphine sulfate er beads...... 6 neostigmine methylsulfate...... 15 norgestimate-ethinyl estradiol MOTOFEN...... 36 NEO-SYNALAR...... 9 triphasic...... 43 moxifloxacin hcl...... 11, 53 nephronex...... 35 norlyda...... 45 moxifloxacin hcl (2x day)...... 53 neuac...... 33 norlyroc...... 45 moxifloxacin hcl in nacl...... 11 NEULASTA...... 26 normal saline flush...... 50 MOZOBIL...... 26 NEULASTA ONPRO...... 26 nortrel 0.5/35 (28)...... 43 multi prenatal...... 35 NEUPRO...... 20 nortrel 1/35 (21)...... 43 multi-vit/iron/fluoride...... 35 nevirapine...... 22 nortrel 1/35 (28)...... 43 multivitamin/fluoride...... 35 nevirapine er...... 22 nortrel 7/7/7...... 43 multi-vitamin/fluoride...... 35 NEXAVAR...... 18 nortriptyline hcl...... 13 multi-vitamin/fluoride/iron...... 35 NEXLETOL...... 30 NORVIR...... 23 mupirocin...... 9 NEXLIZET...... 30 novarel...... 41 mutamycin...... 17 NEXPLANON...... 45 NOVOEIGHT...... 26 MVASI...... 19 niacin er (antihyperlipidemic).... 30 NOVOFINE AUTOCOVER MYALEPT...... 38 nicardipine hcl...... 28 PEN NEEDLE...... 50 mycophenolate mofetil...... 46 NICORETTE...... 8 NOVOFINE PEN NEEDLE...... 50 mycophenolate mofetil hcl...... 46 nicotine polacrilex...... 8 NOVOFINE PLUS PEN mycophenolate sodium...... 46 nicotine step 1...... 8 NEEDLE...... 50 MYLERAN...... 16 nicotine step 2...... 8 NOVOLIN 70/30 FLEXPEN...... 25 myorisan...... 33 nicotine step 3...... 8 NOVOLIN 70/30 FLEXPEN MYRBETRIQ...... 38 NICOTROL...... 8 RELION...... 25 na ferric gluc cplx in sucrose.....34 NICOTROL NS...... 8 NOVOLIN 70/30 RELION...... 25 NABI-HB...... 47 nifedipine er...... 28 NOVOLIN 70/30 VIAL...... 25 nabumetone...... 5 nifedipine er osmotic release.... 28 NOVOLIN N FLEXPEN...... 25 n-acetyl-l-cysteine...... 50 nikki...... 43 NOVOLIN N FLEXPEN nafcillin sodium...... 10 nilutamide...... 16 RELION...... 25 nafrinse...... 34 nimodipine...... 28 NOVOLIN N RELION...... 25 nafrinse drops...... 34 NINLARO...... 17 NOVOLIN N VIAL...... 25 naftifine hcl...... 15 NIPENT...... 17 NOVOLIN R FLEXPEN...... 25 NAGLAZYME...... 38 nisoldipine er...... 28 NOVOLIN R FLEXPEN naloxone hcl...... 8 nitazoxanide...... 20 RELION...... 25 naltrexone hcl...... 8 nitisinone...... 38 NOVOLIN R RELION...... 25 NAMZARIC...... 12 NITRO-BID...... 31 NOVOLIN R VIAL...... 25 naproxen...... 5 nitrofurantoin...... 9 NOVOLOG FLEXPEN...... 25 naproxen sodium...... 6 nitrofurantoin macrocrystal...... 9 NOVOLOG MIX 70/30 naratriptan hcl...... 15 nitrofurantoin monohydrate FLEXPEN...... 25 NARCAN...... 8 macrocrystals...... 9 NOVOLOG MIX 70/30 VIAL...... 25 NASCOBAL...... 35 nitroglycerin...... 31 NOVOLOG PENFILL...... 26 NATACYN...... 52 nitroglycerin in d5w...... 31 NOVOLOG U-100 VIAL...... 26 NATAZIA...... 43 NITROMIST...... 31 NOVOPEN ECHO...... 24 nateglinide...... 25 nitroprusside sodium...... 31 NOVOSEVEN RT...... 26 necon 0.5/35 (28)...... 43 NIVESTYM...... 26 NOVOTWIST PEN NEEDLE.... 50 nefazodone hcl...... 13 nizatidine...... 37 NOZIN NASAL SANITIZER neomycin sulfate...... 8 nora-be...... 45 POPSWAB...... 50 neomycin-bacitracin zn- NORDITROPIN FLEXPRO...... 41 np thyroid...... 45 polymyx...... 52 norepinephrine bitartrate...... 29 NUCALA...... 56 neomycin-polymyxin b gu...... 39 norethin ace-eth estrad-fe...... 43 NUCYNTA ER...... 6 neomycin-polymyxin-dexameth 52 norethindrone...... 45 nufol...... 35 neomycin-polymyxin- norethindrone acetate...... 45 nutrifac zx...... 35 gramicidin...... 51 norethindrone acet-ethinyl est...43 nutrilipid...... 34

67 NUTROPIN AQ NUSPIN 10..... 41 oxacillin sodium...... 10 pentazocine-naloxone hcl...... 7 NUTROPIN AQ NUSPIN 20..... 41 oxaliplatin...... 16 pentobarbital sodium...... 11 NUTROPIN AQ NUSPIN 5...... 41 oxandrolone...... 41 pentoxifylline er...... 29 NUWIQ...... 26 oxaprozin...... 6 PERFOROMIST...... 55 nyamyc...... 15 oxazepam...... 23 perindopril erbumine...... 27 nylia 7/7/7...... 43 oxcarbazepine...... 12 periogard...... 32 nymyo...... 44 oxiconazole nitrate...... 15 PERJETA...... 19 nystatin...... 15 OXISTAT...... 15 permethrin...... 20 nystatin-triamcinolone...... 15 oxybutynin chloride...... 38 perphenazine...... 14 nystop...... 15 oxybutynin chloride er...... 38 perphenazine-amitriptyline...... 13 OBIZUR...... 26 oxycodone hcl...... 7 phenazo...... 39 ocella...... 44 oxycodone-acetaminophen...... 7 phenazopyridine hcl...... 39 OCTAGAM...... 47 oxycodone-aspirin...... 7 phenelzine sulfate...... 13 octreotide acetate...... 45 OXYCONTIN...... 6 phenobarbital...... 11 ODEFSEY...... 22 oxymorphone hcl...... 7 phenobarbital sodium...... 11 OFEV...... 56 oxymorphone hcl er...... 6 phenoxybenzamine hcl...... 27 ofloxacin...... 11, 53, 54 oxytocin...... 41 phentolamine mesylate...... 27 olanzapine...... 21 OZEMPIC...... 25 phenylephrine hcl...... 29, 52 olanzapine-fluoxetine hcl...... 13 paclitaxel...... 17 phenytoin...... 12 olmesartan medoxomil...... 27 PADCEV...... 19 phenytoin infatabs...... 12 olmesartan medoxomil-hctz...... 29 paliperidone er...... 21 phenytoin sodium...... 12 olmesartan-amlodipine-hctz...... 29 palonosetron hcl...... 14 phenytoin sodium extended...... 12 olopatadine hcl...... 52, 54 pamidronate disodium...... 49 philith...... 44 OMECLAMOX-PAK...... 36 PANDA MASK LARGE...... 50 PHOSLYRA...... 35 omega-3-acid ethyl esters...... 30 PANDA MASK MEDIUM...... 50 PHOSPHOLINE IODIDE...... 53 omeprazole...... 37 PANDA MASK SMALL...... 50 phosphorous...... 34 ONCASPAR...... 17 PANRETIN...... 19 phospho-trin 250 neutral...... 34 ondansetron hcl...... 14 pantoprazole sodium...... 37 phytonadione...... 35 ondansetron odt...... 14 PARAGARD INTRAUTERINE PICATO...... 17 ONE VITE WOMENS...... 35 COPPER...... 50 pilocarpine hcl...... 32, 53 ONE-A-DAY WOMENS paraplatin...... 16 pimecrolimus...... 33 PRENATAL 1...... 35 paricalcitol...... 49 pimozide...... 21 ONETOUCH DELICA paromomycin sulfate...... 8 pimtrea...... 44 LANCING DEV...... 24 paroxetine hcl...... 13 pindolol...... 28 ONETOUCH DELICA PLUS paroxetine hcl er...... 13 pioglitazone hcl...... 25 LANCING...... 24 paroxetine mesylate...... 13 pioglitazone hcl-glimepiride...... 25 ONIVYDE...... 17 PASER...... 16 pioglitazone hcl-metformin hcl.. 25 ONUREG...... 17 PAXIL...... 13 piperacillin sod-tazobactam so..10 OPDIVO...... 19 PEDIARIX...... 48 PIQRAY...... 17 OPSUMIT...... 55 PEDIATRIC PANDA MASK...... 50 pirmella 1/35...... 44 oralone...... 32 PEDVAX HIB...... 48 pirmella 7/7/7...... 44 ORENCIA...... 46 peg 3350-kcl-na bicarb-nacl...... 37 piroxicam...... 6 ORENCIA CLICKJECT...... 46 peg-3350/electrolytes...... 37 PNEUMOVAX 23...... 48 ORENITRAM...... 55 peg-3350/electrolytes/ascorbat.37 POCKET SPACER...... 50 ORFADIN...... 38 PEGASYS...... 21 podofilox...... 33 ORKAMBI...... 55 peg-kcl-nacl-nasulf-na asc-c..... 37 POLIVY...... 19 orphenadrine citrate...... 56 penicillamine...... 39 polycin...... 52 orphenadrine citrate er...... 56 penicillin g potassium...... 10 polymyxin b sulfate...... 9 orsythia...... 44 penicillin g sodium...... 10 polymyxin b-trimethoprim...... 52 oscimin...... 36 penicillin v potassium...... 10 polysaccharide iron forte...... 34 oseltamivir phosphate...... 23 PENTACEL...... 48 POMALYST...... 16 OSPHENA...... 45 pentamidine isethionate...... 20 portia-28...... 44 OTEZLA...... 47 PENTASA...... 48 posaconazole...... 15

68 potassium acetate...... 34 PROAIR RESPICLICK...... 55 quinine sulfate...... 20 potassium chloride...... 34 probenecid...... 15 rabeprazole sodium...... 37 potassium chloride crys er...... 34 procainamide hcl...... 28 raloxifene hcl...... 45 potassium chloride er...... 34 PROCARE SPACER/ADULT ramelteon...... 57 potassium chloride in dextrose. 34 MASK...... 51 ramipril...... 27 potassium chloride in nacl...... 34 PROCARE SPACER/CHILD ranolazine er...... 29 potassium citrate er...... 34 MASK...... 51 rasagiline mesylate...... 21 potassium phosphates(71 meq prochlorperazine...... 14 RAVICTI...... 38 k)...... 34 prochlorperazine edisylate...... 14 RAYALDEE...... 49 PRADAXA...... 26 prochlorperazine maleate...... 14 REBLOZYL...... 26 PRALUENT...... 30 procto-med hc...... 48 reclipsen...... 44 pramipexole dihydrochloride..... 20 procto-pak...... 48 RECOMBINATE...... 27 pramipexole dihydrochloride er.20 proctozone-hc...... 48 RECOMBIVAX HB...... 48 prasugrel hcl...... 27 PROFILNINE...... 27 RECTIV...... 31 pravastatin sodium...... 30 progesterone...... 45 REGRANEX...... 33 praziquantel...... 19 progesterone micronized...... 45 RELENZA DISKHALER...... 23 prazosin hcl...... 27 PROGRAF...... 46 relexxii...... 31 prednicarbate...... 40 PROLASTIN-C...... 38 RENACIDIN...... 39 prednisolone...... 40 PROLENSA...... 53 RENFLEXIS...... 46 prednisolone acetate...... 53 PROLEUKIN...... 17 repaglinide...... 25 prednisolone sodium PROLIA...... 49 REPATHA...... 30 phosphate...... 40, 53 PROMACTA...... 26 REPATHA PUSHTRONEX prednisone...... 40 promethazine hcl...... 54 SYSTEM...... 31 prednisone intensol...... 40 promethegan...... 54 REPATHA SURECLICK...... 31 pregabalin...... 31 propafenone hcl...... 28 RESTASIS...... 52 pregnyl...... 41 propafenone hcl er...... 28 RESTASIS MULTIDOSE...... 52 PREMARIN...... 44 propranolol hcl...... 28 RETACRIT...... 26 PREMPHASE...... 44 propranolol hcl er...... 28 RETROVIR...... 22 PREMPRO...... 44 propranolol-hctz...... 29 REVCOVI...... 38 prenatal...... 36 propylthiouracil...... 46 REVLIMID...... 16 prenatal multi +dha...... 35 PROQUAD...... 48 revonto...... 56 prenatal plus iron...... 36 ...... 27 REXULTI...... 21 prenatal vitamin plus low iron....36 protriptyline hcl...... 13 REYATAZ...... 23 preplus...... 36 PULMICORT FLEXHALER...... 54 RHOGAM ULTRA-FILTERED prevalite...... 30 PULMOZYME...... 55 PLUS...... 47 preventeza...... 45 purevit dualfe plus...... 34 RHOPHYLAC...... 47 prevident...... 32 PYLERA...... 36 RHOPRESSA...... 53 previfem...... 44 pyrazinamide...... 16 RIASTAP...... 27 PREVNAR 13...... 48 pyridostigmine bromide...... 16 ribavirin...... 21 PREZCOBIX...... 23 pyridostigmine bromide er...... 16 rifabutin...... 16 PREZISTA...... 23 pyridoxine hcl...... 36 rifampin...... 16 PRIFTIN...... 16 pyrimethamine...... 20 riluzole...... 31 primaquine phosphate...... 20 qc aspirin low dose...... 6 rimantadine hcl...... 23 primidone...... 12 qc magnesium citrate...... 37 ringers...... 34 PRIMSOL...... 9 QINLOCK...... 18 ringers irrigation...... 51 PRIVIGEN...... 47 QUADRACEL...... 48 RINVOQ...... 47 PRO COMFORT SPACER quetiapine fumarate...... 21 risedronate sodium...... 49 ADULT...... 50 quetiapine fumarate er...... 21 RISPERDAL CONSTA...... 21 PRO COMFORT SPACER QUILLIVANT XR...... 31 risperidone...... 21 CHILD...... 50 quinapril hcl...... 27 ritonavir...... 23 PRO COMFORT SPACER quinapril-hydrochlorothiazide.... 29 RITUXAN...... 19 INFANT...... 51 quinidine gluconate er...... 28 RITUXAN HYCELA...... 19 PROAIR HFA...... 55 quinidine sulfate...... 28 rivastigmine...... 12

69 rivastigmine tartrate...... 12 SKLICE...... 19 subvenite starter kit-green...... 12 rivelsa...... 44 SKYLA...... 45 subvenite starter kit-orange...... 12 RIXUBIS...... 27 SKYRIZI (150 MG DOSE)...... 46 SUCRAID...... 38 rizatriptan benzoate...... 15 sod benz-sod phenylacet...... 38 sucralfate...... 37 ROCKLATAN...... 53 sod citrate-citric acid...... 34 sulfacetamide sodium...... 53 ropinirole hcl...... 20 sodium acetate...... 34 sulfacetamide sodium (acne).... 33 ropinirole hcl er...... 20 sodium bicarbonate...... 34, 36 sulfacetamide-prednisolone...... 52 rosadan...... 33 sodium chloride...... 34, 39, 56 sulfadiazine...... 11 rosuvastatin calcium...... 30 sodium chloride (pf)...... 34 sulfamethoxazole-trimethoprim.11 ROTARIX...... 48 sodium chloride flush...... 51 sulfasalazine...... 48 ROTATEQ...... 48 sodium fluoride...... 32, 35 sulfatrim pediatric...... 11 roweepra...... 11 sodium fluoride 5000 enamel....32 sulfurated lime...... 20 ROZLYTREK...... 17 sodium fluoride 5000 plus...... 32 sulindac...... 6 RUBRACA...... 18 sodium fluoride 5000 ppm...... 32 sumatriptan...... 15 rufinamide...... 12 sodium fluoride 5000 sensitive..32 sumatriptan succinate...... 15 RUKOBIA...... 23 ...... 51 sumatriptan succinate refill...... 15 RUXIENCE...... 19 sodium nitroprusside...... 31 sumatriptan-naproxen sodium.. 15 RYDAPT...... 18 sodium phenylbutyrate...... 38 SUNOSI...... 57 ryvent...... 54 sodium phosphates...... 35 SUPREP BOWEL PREP KIT....37 saline flush...... 51 sodium polystyrene sulfonate... 35 SUTENT...... 18 saline flush zr...... 51 sodium thiosulfate...... 51 swabflush saline flush...... 51 salsalate...... 6 solifenacin succinate...... 38 syeda...... 44 SANDIMMUNE...... 46 SOLIRIS...... 26 SYMBICORT...... 54 SANTYL...... 33 SOLTAMOX...... 16 SYMFI...... 22 SAPHRIS...... 21 SOLU-CORTEF...... 40 SYMFI LO...... 22 sapropterin dihydrochloride...... 38 SOMATULINE DEPOT...... 45 SYMPROIC...... 36 SAVAYSA...... 26 SOMAVERT...... 45 SYNAGIS...... 47 SAVELLA...... 31 sorbitol...... 39 SYNAREL...... 46 SAVELLA TITRATION PACK... 32 sorbitol-mannitol...... 39 SYNJARDY...... 25 scopolamine...... 14 sorine...... 28 SYNJARDY XR...... 25 selegiline hcl...... 21 sotalol hcl...... 28 SYNRIBO...... 17 selenium sulfide...... 33 sotalol hcl (af)...... 28 TABLOID...... 17 SELZENTRY...... 23 spinosad...... 20 tacrolimus...... 33, 46 SEREVENT DISKUS...... 55 SPIRIVA HANDIHALER...... 55 tadalafil...... 38 sertraline hcl...... 13 SPIRIVA RESPIMAT...... 55 tadalafil (pah)...... 56 se-tan plus...... 34 spironolactone...... 30 TAFINLAR...... 18 setlakin...... 44 spironolactone-hctz...... 29 TAGRISSO...... 19 sevelamer carbonate...... 35 sprintec 28...... 44 TALTZ...... 33 sevelamer hcl...... 35 SPRYCEL...... 18 tamoxifen citrate...... 16 sharobel...... 45 sps...... 35 tamsulosin hcl...... 38 SHINGRIX...... 48 sronyx...... 44 TARGRETIN...... 19 SIGNIFOR...... 45 ssd...... 9 tarina 24 fe...... 44 sildenafil citrate...... 55, 56 ST JOSEPH LOW DOSE...... 6 tarina fe 1/20...... 44 silodosin...... 38 stavudine...... 22 tarina fe 1/20 eq...... 44 silver sulfadiazine...... 9 STELARA...... 33 TASIGNA...... 19 SIMBRINZA...... 53 sterile water for irrigation...... 51 tavaborole...... 15 simliya...... 44 STIOLTO RESPIMAT...... 55 tazarotene...... 33 simpesse...... 44 STIVARGA...... 18 tazicef...... 10 SIMPONI...... 46 STRENSIQ...... 38 TAZORAC...... 33 SIMPONI ARIA...... 46 streptomycin sulfate...... 8 taztia xt...... 28 simvastatin...... 30 STRIBILD...... 22 TDVAX...... 48 sirolimus...... 46 subvenite...... 12 TECENTRIQ...... 19 SIRTURO...... 16 subvenite starter kit-blue...... 12 TECFIDERA...... 32

70 TEGSEDI...... 38 tolmetin sodium...... 6 tri-lo-sprintec...... 44 telmisartan...... 27 tolterodine tartrate...... 38 trimethoprim...... 9 telmisartan-amlodipine...... 29 tolterodine tartrate er...... 38 tri-mili...... 44 telmisartan-hctz...... 29 topiramate...... 12 trimipramine maleate...... 14 temazepam...... 56 topiramate er...... 12 TRINTELLIX...... 13 TEMODAR...... 16 toposar...... 18 tri-nymyo...... 44 temozolomide...... 16 topotecan hcl...... 18 tri-previfem...... 44 temsirolimus...... 46 toremifene citrate...... 16 tri-sprintec...... 44 teniposide...... 17 torsemide...... 30 TRIUMEQ...... 22 TENIVAC...... 48 TOTECT...... 17 tri-vite/fluoride...... 36 tenofovir disoproxil fumarate.....22 TOUJEO MAX SOLOSTAR...... 26 trivora (28)...... 44 terazosin hcl...... 39 TOUJEO SOLOSTAR...... 26 tri-vylibra...... 44 terbinafine hcl...... 15 tovet...... 40 tri-vylibra lo...... 44 terconazole...... 15 TOVIAZ...... 38 TROGARZO...... 23 TERIPARATIDE TRACLEER...... 56 trospium chloride...... 38 (RECOMBINANT)...... 49 TRADJENTA...... 25 trospium chloride er...... 38 testosterone...... 41 tramadol hcl er...... 6 TRUE COMFORT PRO testosterone cypionate...... 41 tramadol hcl er (biphasic)...... 6 ALCOHOL PREP...... 51 testosterone enanthate...... 41 tramadol hcl ir...... 7 TRUE COMFORT PRO TETANUS-DIPHTHERIA tramadol-acetaminophen...... 7 INSULIN SYR...... 51 TOXOIDS TD...... 48 trandolapril...... 27 TRUE COMFORT PRO PEN tetrabenazine...... 31 trandolapril-verapamil hcl er...... 29 NEEDLES...... 51 tetracycline hcl...... 11 tranexamic acid...... 27 TRULICITY...... 25 TEXACORT...... 40 tranylcypromine sulfate...... 13 TRUMENBA...... 48 THALOMID...... 16 travoprost (bak free)...... 53 TRUVADA...... 22 THEO-24...... 55 TRAZIMERA...... 19 TUKYSA...... 19 theophylline...... 55 trazodone hcl...... 13 tulana...... 45 theophylline er...... 55 TRECATOR...... 16 TURALIO...... 19 theophylline in d5w...... 55 TRELEGY ELLIPTA...... 55, 56 TUZISTRA XR...... 56 thiamine hcl...... 36 TREMFYA...... 33 TWINRIX...... 48 thioridazine hcl...... 21 treprostinil...... 56 tyblume...... 44 thiothixene...... 21 TRESIBA...... 26 TYBOST...... 22 THROMBATE III...... 26 TRESIBA FLEXTOUCH...... 26 tydemy...... 44 THYMOGLOBULIN...... 47 tretinoin...... 19, 33 TYKERB...... 19 THYROGEN...... 51 tretinoin microsphere...... 33 TYSABRI...... 32 tiadylt er...... 28 tretinoin microsphere pump...... 33 TYVASO...... 56 tiagabine hcl...... 12 TREXALL...... 46 TYVASO REFILL...... 56 tilia fe...... 44 tri femynor...... 44 TYVASO STARTER...... 56 timolol maleate...... 28, 53 triamcinolone acetonide 32, 40, 41 ULTIGUARD SAFEPACK timolol maleate pf...... 53 triamterene...... 30 SYR/NEEDLE...... 51 tinidazole...... 9 triamterene-hctz...... 29 ULTOMIRIS...... 47 TIVICAY...... 22 triazolam...... 23 unithroid...... 45 TIVICAY PD...... 22 triderm...... 41 UNITUXIN...... 19 tizanidine hcl...... 56 trientine hcl...... 35 UPTRAVI...... 56 tl-hem 150...... 35 tri-estarylla...... 44 urin ds...... 38 TOBRADEX...... 51 trifluoperazine hcl...... 21 ursodiol...... 36 TOBRADEX ST...... 51 trifluridine...... 52 valacyclovir hcl...... 22 tobramycin...... 51, 55 trihexyphenidyl hcl...... 20 valganciclovir hcl...... 21 tobramycin sulfate...... 8 tri-legest fe...... 44 valproate sodium...... 12 tobramycin-dexamethasone...... 51 tri-linyah...... 44 valproic acid...... 12 TOBREX...... 51 tri-lo-estarylla...... 44 valsartan...... 27 TODAY SPONGE...... 39 tri-lo-marzia...... 44 valsartan-hydrochlorothiazide... 30 tolcapone...... 20 tri-lo-mili...... 44 vancomycin hcl...... 9

71 vancomycin hcl in dextrose...... 9 vp-vite rx...... 36 zidovudine...... 23 vancomycin hcl in nacl...... 9 vyfemla...... 44 zileuton er...... 54 VANCOMYCIN HCL IN NACL.... 9 vylibra...... 44 ZIOPTAN...... 53 VAQTA...... 48 VYNDAMAX...... 30 ziprasidone hcl...... 21 VARIVAX...... 48 VYVANSE...... 31 ziprasidone mesylate...... 21 VAXELIS...... 48 VYXEOS...... 18 ZIRABEV...... 19 v-c forte...... 36 warfarin sodium...... 26 ZIRGAN...... 52 VCF VAGINAL water for irrigation, sterile...... 51 ZITHROMAX...... 11 CONTRACEPTIVE...... 39 wera...... 44 ZOKINVY...... 51 vcf vaginal contraceptive...... 39 westab mini...... 36 zoledronic acid...... 49 VELCADE...... 17 westab one...... 36 ZOLINZA...... 18 VELETRI...... 56 WIDE-SEAL DIAPHRAGM 60.. 51 ZOLMITRIPTAN...... 15 velivet...... 44 WIDE-SEAL DIAPHRAGM 65.. 51 zolmitriptan...... 15 VELTASSA...... 35 WIDE-SEAL DIAPHRAGM 70.. 51 zolpidem tartrate...... 56 VEMLIDY...... 21 WIDE-SEAL DIAPHRAGM 75.. 51 zolpidem tartrate er...... 56 VENCLEXTA...... 19 WIDE-SEAL DIAPHRAGM 80.. 51 ZOMIG...... 15 VENCLEXTA STARTING WIDE-SEAL DIAPHRAGM 85.. 51 zonisamide...... 11 PACK...... 19 WIDE-SEAL DIAPHRAGM 90.. 51 ZONTIVITY...... 26 venlafaxine hcl...... 13 WIDE-SEAL DIAPHRAGM 95.. 51 ZORTRESS...... 47 venlafaxine hcl er...... 13 WINRHO SDF...... 47 zovia 1/35 (28)...... 44 VENTAVIS...... 56 wixela inhub...... 54 zovia 1/35e (28)...... 44 VENTOLIN HFA...... 55 wymzya fe...... 44 zumandimine...... 44 verapamil hcl...... 28 XALKORI...... 19 ZYDELIG...... 19 verapamil hcl er...... 28 XARELTO...... 26 ZYKADIA...... 19 vestura...... 44 XARELTO STARTER PACK.....26 ZYPREXA RELPREVV...... 21 VICTOZA...... 25 XELJANZ...... 47 ZYVOX...... 9 vienva...... 44 XELJANZ XR...... 47 VIIBRYD...... 13 XGEVA...... 49 VIIBRYD STARTER PACK...... 13 XIAFLEX...... 51 VIMIZIM...... 38 XIFAXAN...... 9 VIMPAT...... 12 XIGDUO XR...... 25 vinblastine sulfate...... 18 XIIDRA...... 52 vincristine sulfate...... 18 XOLAIR...... 47 vinorelbine tartrate...... 18 XTAMPZA ER...... 6 viorele...... 44 XTANDI...... 16 VIRACEPT...... 23 xulane...... 44 VIREAD...... 22, 23 XYNTHA...... 27 virt-caps...... 36 XYNTHA SOLOFUSE...... 27 virt-gard...... 36 YERVOY...... 19 virt-phos 250 neutral...... 35 yuvafem...... 44 VISTOGARD...... 51 zafemy...... 44 vita s forte...... 36 zafirlukast...... 54 vitacel...... 36 zaleplon...... 56 vita-min...... 36 ZALTRAP...... 18 vitamin d (ergocalciferol)...... 36 ZANOSAR...... 16 vitamin k1...... 36 zarah...... 44 vitamins acd-fluoride...... 36 ZELBORAF...... 19 VIVITROL...... 8 ZEMAIRA...... 38 volnea...... 44 zenatane...... 33 VONVENDI...... 27 ZENPEP...... 38 voriconazole...... 15 ZEPATIER...... 22 VOTRIENT...... 19 ZEPZELCA...... 16 vp-pnv-dha...... 36 ZERVIATE...... 52

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